Gender and equity in health sector reform programmes: a review.
(57/5036)
This paper reviews current literature and debates about Health Sector Reform (HSR) in developing countries in the context of its possible implications for women's health and for gender equity. It points out that gender is a significant marker of social and economic vulnerability which is manifest in inequalities of access to health care and in women's and men's different positioning as users and producers of health care. Any analysis of equity must therefore include a consideration of gender issues. Two main approaches to thinking about gender issues in health care are distinguished--a 'women's health' approach, and a 'gender inequality' approach. The framework developed by Cassels (1995), highlighting six main components of HSR, is used to try to pinpoint the implications of HSR in relation to both of these approaches. This review makes no claim to sociological or geographical comprehensiveness. It attempts instead to provide an analysis of the gender and women's health issues most likely to be associated with each of the major elements of HSR and to outline an agenda for further research. It points out that there is a severe paucity of information on the actual impact of HSR from a gender point of view and in relation to substantive forms of vulnerability (e.g. particular categories of women, specific age groups). The use of generic categories, such as 'the poor' or 'very poor', leads to insufficient disaggregation of the impact of changes in the terms on which health care is provided. This suggests the need for more carefully focused data collection and empirical research. (+info)
Health seeking behaviour and the control of sexually transmitted disease.
(58/5036)
What people do when they have symptoms or suspicion of a sexually transmitted disease (STD) has major implications for transmission and, consequently, for disease control. Delays in seeking and obtaining diagnosis and treatment can allow for continued transmission and the greater probability of adverse sequelae. An understanding of health seeking behaviour is therefore important if STD control programmes are to be effective. However, taboos and stigma related to sex and STD in most cultures mean that gaining a true picture is difficult and requires considerable cultural sensitivity. At the moment relatively little is known about who people turn to for advice, or about how symptoms are perceived, recognized or related to decisions to seek help. It is argued that such knowledge would assist programme planners in the development of more accessible and effective services, that studies of health seeking behaviour need to include a combination of qualitative and quantitative methods, and that studies should include data collection about people who do not present to health care facilities as well as those who do. A pilot protocol for studying STD-related health seeking behaviour in developing countries is briefly presented. (+info)
Using cost-effectiveness analysis to evaluate targeting strategies: the case of vitamin A supplementation.
(59/5036)
Given the demonstrated efficacy of vitamin A supplements in reducing childhood mortality, health officials now have to decide whether it would be efficient to target the supplements to high risk children. Decisions about targeting are complex because they depend on a number of factors; the degree of clustering of preventable deaths, the cost of the intervention, the side-effects of the intervention, the cost of identifying the high risk group, and the accuracy of the 'diagnosis' of risk. A cost-effectiveness analysis was used in the Philippines to examine whether vitamin A supplements should be given universally to all children 6-59 months, targeted broadly to children suffering from mild, moderate, or severe malnutrition, or targeted narrowly to pre-schoolers with moderate and severe malnutrition. The first year average cost of the universal approach was US$67.21 per death averted compared to $144.12 and $257.20 for the broad and narrow targeting approaches respectively. When subjected to sensitivity analysis the conclusion about the most cost-effective strategy was robust to changes in underlying assumptions such as the efficacy of supplements, clustering of deaths, and toxicity. Targeting vitamin A supplements to high risk children is not an efficient use of resources. Based on the results of this cost-effectiveness analysis and a consideration of alternate strategies, it is apparent that vitamin A, like immunization, should be provided to all pre-schoolers in the developing world. Issues about targeting public health interventions can usefully be addressed by cost-effectiveness analysis. (+info)
Health policy development in wartime: establishing the Baito health system in Tigray, Ethiopia.
(60/5036)
This paper documents health experiences and the public health activities of the Tigray People's Liberation Front (TPLF). The paper provides background data about Tigray and the emergence of its struggle for a democratic Ethiopia. The origins of the armed struggle are described, as well as the impact of the conflict on local health systems and health status. The health-related activities and public health strategies of the TPLF are described and critiqued in some detail, particular attention is focused on the development of the baito system, the emergent local government structures kindled by the TPLF as a means of promoting local democracy, accountability, and social and economic development. Important issues arise from this brief case-study, such as how emerging health systems operating in wartime can ensure that not only are basic curative services maintained, but preventive and public health services are developed. Documenting the experiences of Tigray helps identify constraints and possibilities for assisting health systems to adapt and cope with ongoing conflict, and raises possibilities that in their aftermath they leave something which can be built upon and further developed. It appears that promoting effective local government may be an important means of promoting primary health care. (+info)
Operational factors affecting maternal mortality in Tanzania.
(61/5036)
Identification of the main operational factors in cases of maternal death within and outside the health care system is necessary for safe motherhood programmes. In this study, a follow-up was done of all 117 cases of maternal deaths in Ilala district, Dar es Salaam, 1991-1993, at all levels of care. In all, 79% received some medical care whereas 11% arrived too late for treatment. For each case the major operational factors and all health care interventions were defined through interviews with family members and health care staff and from hospital records, and the avoidability of each case was determined. In the health institutions where the women had consulted, the available resources were assessed. It was found that in most cases the husband (29%) or the mother (31%) of the woman decided on her care in cases of complications, and together with the lack of transport, this often caused delay at home. Also, delay in transfer from the district hospital was common. Cases of abortion complications were often not managed on time because of the delay in reporting to hospital or misleading information. Suboptimal care was identified in 77% of the cases reaching health care. Inadequate treatment was identified by the district health staff in 61% and by the referral centres in 12% of their cases. Wrong decision at the district level and lack of equipment at the referral centre were the main reasons for inadequate care. It is concluded that although community education on danger signs in pregnancy and labour is important, provision of the core resources and supplies for emergency obstetric interventions, as well as clear protocols for management and referral, are absolutely necessary for improvement of maternal survival. (+info)
The status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used?
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During 1980-1990 BRAC, a Bangladeshi non-governmental organization, taught over 12 million mothers how to prepare oral rehydration therapy (ORT) at home with lobon (common salt) and gur (unrefined brown sugar). This was followed by a strong promotion and distribution of prepackaged ORS by various agencies including the government. In 1993 we assessed knowledge of ORT preparation, its local availability and its use for the management of diarrhoea. Over 9000 households in 90 villages were revisited; 306 government outreach health workers, 296 drug sellers, and 237 village doctors were interviewed; 152 government facilities and 495 pharmacies/shops were visited. ORT prepared by mothers in a sub-sample of the households was analyzed for chloride content and interviewers collected information on use of ORT for diarrhoeal episodes occurring in the preceding two weeks. The data quality was assessed through a resurvey of sample respondents within two weeks of the first interview. Over 70% of the mothers could prepare a chemically 'safe and effective' ORS. A significant proportion of these mothers were very young at the time of the mass campaigns using house to house teaching, implying an intergenerational transfer of the knowledge on ORT. ORT was found to be used in 60% of all diarrhoeal episodes, but the rate varied with the type of diarrhoea, being highest for daeria (severe watery diarrhoea) and lowest for amasha (dysentery). Drug sellers and village doctors now recommend ORT much more frequently than before. Members of the medical profession (qualified and unqualified) still lag behind in prescribing the use of ORT. The availability of pre-packaged ORS in rural pharmacies has improved enormously. There is convincing evidence that the widescale promotion in the past of ORS for dehydration in diarrhoea has led to this marked improvement today. Nevertheless the use of rice-based ORS, culturally appropriate messages and the promotion of ORS with food offer opportunities to further improve the utilization of ORT. (+info)
Sustaining malaria prevention in Benin: local production of bednets.
(63/5036)
Through a Benin-Canada participatory research initiative which included both Benin and Canadian non-governmental organizations, a local capacity to produce and market bednets for the prevention of malaria was developed. The development process began following a community-based assessment of local needs and skills. All materials for the manufacture and distribution of the bednets were obtained locally with the exception of the netting which was imported from Canada. The sustainability of the enterprise is enhanced by the community's recognition of the importance of malaria and the culturally acceptable practice of bednet use. (+info)
Reducing perinatal mortality in developing countries.
(64/5036)
The perinatal mortality rate (PNMR) is a key health status indicator. It is multifactorial in aetiology and is significantly influenced by the quality of health care. While there is an ethical imperative to act to improve quality of care when deficiencies are apparent, the lack of controls--when an interventions is applied to an entire service--makes it difficult to infer a causal relationship between the intervention and any subsequent change in PNMR. However, by specifically measuring avoidable perinatal deaths (those due to error or omission on the part of the health service), this limitation is partially overcome, and the impact of the intervention can be more rigorously evaluated. This paper reports the impact of perinatal audit in a rural African health district between 1991 and 1995. A total of 21,112 consecutive births were studied: the average number of deliveries increased by 31% from 325 to 424 per month. The PNMR (birth weight > or = 1000g) in 1991 was 27/1000, increased to 42/1000 in 1992, and fell steadily to 26/1000 in 1995 (40% reduction; p = 0.002). The proportion of avoidable deaths fell from 19% in 1991 to zero in the second half of 1995 (p = 0.0008). While factors associated with perinatal mortality are many, complex, and interrelated, this report suggests that mortality can be reduced significantly in resource-poor settings by improving quality of health care. Including the measurement of avoidable deaths in perinatal audit allows the impact of interventions to be more rigorously assessed than by simple measuring the PNMR. (+info)