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Tasnim Hossain A, Hazel EA, Rahman AE, Koon AD, Jue Wong H, Maïga A, Akseer N, Tam Y, Walker N, Jiwani SS, Munos MK, El Arifeen S, Black R, Amouzou A. Effective multi-sectoral approach for rapid reduction in maternal and neonatal mortality: the exceptional case of Bangladesh. BMJ Glob Health 2024; 9:e011407. [PMID: 38770805 PMCID: PMC11085986 DOI: 10.1136/bmjgh-2022-011407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/20/2023] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Bangladesh experienced impressive reductions in maternal and neonatal mortality over the past several decades with annual rates of decline surpassing 4% since 2000. We comprehensively assessed health system and non-health factors that drove Bangladesh's success in mortality reduction. METHODS We operationalised a comprehensive conceptual framework and analysed available household surveys for trends and inequalities in mortality, intervention coverage and quality of care. These include 12 household surveys totalling over 1.3 million births in the 15 years preceding the surveys. Literature and desk reviews permitted a reconstruction of policy and programme development and financing since 1990. These were supplemented with key informant interviews to understand implementation decisions and strategies. RESULTS Bangladesh prioritised early population policies to manage its rapidly growing population through community-based family planning programmes initiated in mid-1970s. These were followed in the 1990s and 2000s by priority to increase access to health facilities leading to rapid increases in facility delivery, intervention coverage and access to emergency obstetric care, with large contribution from private facilities. A decentralised health system organisation, from communities to the central level, openness to private for-profit sector growth, and efficient financing allocation to maternal and newborn health enabled rapid progress. Other critical levers included poverty reduction, women empowerment, rural development, and culture of data generation and use. However, recent empirical data suggest a slowing down of mortality reductions. CONCLUSION Bangladesh demonstrated effective multi-sectoral approach and persistent programming, testing and implementation to achieve rapid gains in maternal and neonatal mortality reduction. The slowing down of recent mortality trends suggests that the country will need to revise its strategies to achieve the Sustainable Development Goals. As fertility reached replacement level, further gains in maternal and neonatal mortality will require prioritising universal access to quality facility delivery, and addressing inequalities, including reaching the rural poor.
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Affiliation(s)
- Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Elizabeth A Hazel
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ahmed Ehsanur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Adam D Koon
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Heather Jue Wong
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abdoulaye Maïga
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nadia Akseer
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Yvonne Tam
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neff Walker
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Safia S Jiwani
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda Kay Munos
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh, (icddr,b), Dhaka, Bangladesh
| | - Robert Black
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Agbessi Amouzou
- International Health Department, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Rojas-Botero ML, Borrero-Ramírez YE, Cáceres-Manrique FDM. [Social inequalities in under-five mortality: a systematic review]. Rev Salud Publica (Bogota) 2023; 22:220-237. [PMID: 36753114 DOI: 10.15446/rsap.v22n2.86964] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/10/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To identify the characteristics of the published studies on social inequalities in under-five mortality, their theoretical perspectives, axes of inequality, methods and results. METHOD We carried out a systematic literature review. We consulted four electronic databases and Google Scholar, for studies published between 2010 and 2018. RESULTS We analyzed 126 articles. In 62.7%, territory was studied as the axis of inequality, followed by socioeconomic determinants (27.8%). Neonatal, infant and under-five mortality was analyzed as an output in health in 19.0%, 49.2% and 32.3%, respectively. It predominated ecological (62.7%) and longitudinal (50.0%) studies. Significant reductions in mortality rates were found, however, the decline was not homogeneous among subpopulations. CONCLUSIONS The literature reports a marked decrease in under-five mortality; however, the gaps between different axes of inequality continue and in some cases they have increased. Gaps varied according to time, place, axis of inequality and type of mortality analyzed.
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Affiliation(s)
- Maylen L Rojas-Botero
- MR: Profesional en Gerencia de Sistemas de Información en Salud, M.Sc. Epidemiología. Ph.D.(c) Epidemiología. Universidad de Antioquia, Facultad Nacional de Salud Pública. Medellín, Colombia.
| | - Yadira E Borrero-Ramírez
- YB: MD. Esp. Teoría Métodos de Investigación. M.Sc. Sociología. Ph.D. Salud Pública. Posdoctorado en Salud Colectiva. Universidad de Antioquia, Facultad Nacional de Salud Pública.
| | - Flor de María Cáceres-Manrique
- FC: Enfermera. Esp.; M.Sc. Epidemiología. Esp. Docencia Universitaria. Ph.D. Salud Pública. Universidad Industrial de Santander, Facultad de Salud, Escuela de Medicina, Departamento de Salud Pública. Bucaramanga, Colombia.
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Johnson S, Frech A, Edwards B, Tumin D. Does the evidence base on social determinants of health cross disciplinary boundaries? A review of reviews. WORLD MEDICAL & HEALTH POLICY 2022. [DOI: 10.1002/wmh3.552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sydney Johnson
- School of Medicine University of Louisville Louisville Kentucky USA
| | - Adrianne Frech
- Department of Health Sciences University of Missouri Columbia Missouri USA
| | - Bob Edwards
- Department of Sociology East Carolina University Greenville North Carolina USA
| | - Dmitry Tumin
- Department of Pediatrics Brody School of Medicine at East Carolina University Greenville North Carolina USA
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Yu H, Peng Y, Pu L. Study on the Impact of Government Health Expenditure Equity on Residents' Health Level in the Chengdu-Chongqing Economic Circle of China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12758. [PMID: 36232058 PMCID: PMC9566478 DOI: 10.3390/ijerph191912758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND When the global COVID-19 epidemic continues to spread, residents pay more attention to their health. This paper studies the relationship between the equity of government health expenditure and the health level of residents. METHODS The Theil index and a principal component analysis were used to measure the equity of government health expenditure and the health level of residents in the Chengdu-Chongqing economic circle. Then, an empirical study on the relationship between the equity of government health expenditure and the health level of residents in this region was conducted with the System GMM model. RESULTS 1. The Theil index rose from 0.0115 in 2015 to 0.0231 in 2017 and gradually decreased to 0.0106 in 2020. 2. The overall health level of residents showed an upward trend, rising from 1.95 in 2015 to 2.33 in 2017, then remained high and fluctuated slightly. 3. There was a positive correlation between the Theil index and the health level of residents at a significance level of 1% (β = 0.903, p < 0.01). CONCLUSIONS 1. The Theil index was close to 0, indicating that the equity of government health expenditure in the Chengdu-Chongqing economic circle was generally good. 2. The health level of residents in the Chengdu-Chongqing economic circle had improved compared to before. 3. The fairer the government's health expenditure, the higher the residents' health level.
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Affiliation(s)
- Haidong Yu
- School of Public Health, Chongqing Medical University, Chongqing 400016, China
- Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing 400016, China
- Research Center for Public Health Security, Chongqing Medical University, Chongqing 400016, China
| | - Yujie Peng
- School of Public Health, Chongqing Medical University, Chongqing 400016, China
- Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing 400016, China
- Research Center for Public Health Security, Chongqing Medical University, Chongqing 400016, China
| | - Lanfang Pu
- School of Public Health, Chongqing Medical University, Chongqing 400016, China
- Research Center for Medicine and Social Development, Chongqing Medical University, Chongqing 400016, China
- Research Center for Public Health Security, Chongqing Medical University, Chongqing 400016, China
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Bekele T, Rawstorne P, Rahman B. Socioeconomic inequalities in child growth failure in Ethiopia: findings from the 2000 and 2016 Demographic and Health Surveys. BMJ Open 2021; 11:e051304. [PMID: 34907054 PMCID: PMC8672003 DOI: 10.1136/bmjopen-2021-051304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Socioeconomic inequalities in child growth failure (CGF) remain one of the main challenges in Ethiopia. This study examined socioeconomic inequalities in CGF and determinants that contributed to these inequalities in Ethiopia. METHODS The Ethiopia Demographic and Health Surveys 2000 and 2016 data were used in this study. A pooled unweighted sample of the two surveys yielded 21514 mother-child pairs (10873 in 2000 and 10641 in 2016). We assessed socioeconomic inequalities in CGF indicators using the concentration curve and concentration index (CI). We then decomposed the CI to identify percentage contribution of each determinant to inequalities. RESULTS Socioeconomic inequalities in CGF have increased in Ethiopia between 2000 and 2016. The CI increased from -0.072 and -0.139 for stunting, -0.088 and -0.131 for underweight and -0.015 and -0.050 for wasting between 2000 and 2016, respectively. Factors that mainly contributed to inequalities in stunting included geographical region (49.43%), number of antenatal care visits (31.40%) and child age in months (22.20%) in 2000. While in 2016, inequality in stunting was contributed mainly by wealth quintile (46.16%) and geographical region (-13.70%). The main contributors to inequality in underweight were geographical regions (82.21%) and wealth quintile (27.21%) in 2000, while in 2016, wealth quintile (29.18%), handwashing (18.59%) and access to improved water facilities (-17.55%) were the main contributors. Inequality in wasting was mainly contributed to by maternal body mass index (-66.07%), wealth quintile (-45.68%), geographical region (36.88%) and paternal education (33.55%) in 2000, while in 2016, wealth quintile (52.87%) and urban areas of residence (-17.81%) were the main driving factors. CONCLUSIONS This study identified substantial socioeconomic inequalities in CGF, and factors that relatively contributed to the disparities. A plausible approach to tackling rising disparities may involve developing interventions on the identified predictors and prioritising actions for the most socioeconomically disadvantaged groups.
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Affiliation(s)
- Tolesa Bekele
- Department of Public Health, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Patrick Rawstorne
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bayzidur Rahman
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
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Assessing the effects of disease-specific programs on health systems: An analysis of the Bangladesh Lymphatic Filariasis Elimination Program's impacts on health service coverage and catastrophic health expenditure. PLoS Negl Trop Dis 2021; 15:e0009894. [PMID: 34813600 PMCID: PMC8651132 DOI: 10.1371/journal.pntd.0009894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 12/07/2021] [Accepted: 10/10/2021] [Indexed: 11/19/2022] Open
Abstract
This study presents a methodology for using tracer indicators to measure the effects of disease-specific programs on national health systems. The methodology is then used to analyze the effects of Bangladesh’s Lymphatic Filariasis Elimination Program, a disease-specific program, on the health system. Using difference-in-differences models and secondary data from population-based household surveys, this study compares changes over time in the utilization rates of eight essential health services and incidences of catastrophic health expenditures between individuals and households, respectively, of lymphatic filariasis hyper-endemic districts (treatment districts) and of hypo- and non-endemic districts (control districts). Utilization of all health services increased from year 2000 to year 2014 for the entire population but more so for the population living in treatment districts. However, when the services were analyzed individually, the difference-in-differences between the two populations was insignificant. Disadvantaged populations (i.e., populations that lived in rural areas, belonged to lower wealth quintiles, or did not attend school) were less likely to access essential health services. After five years of program interventions, households in control districts had a lower incidence of catastrophic health expenditures at several thresholds measured using total household expenditures and total non-food expenditures as denominators. Using essential health service coverage rates as outcome measures, the Lymphatic Filariasis Elimination Program cannot be said to have strengthened or weakened the health system. We can also say that there is a positive association between the Lymphatic Filariasis Elimination Program’s interventions and lowered incidence of catastrophic health expenditures. Evidence to understand the interactions between disease specific programs and the health system is insufficient and largely based on opinion. This study presents a methodology for using tracer indicators to measure the effect of a disease-specific program, the Bangladesh Lymphatic Filariasis Elimination Program, on its health system. The Composite Coverage Index and incidence of catastrophic health expenditures are well-established tracer indicators for measuring the strength of a health system. In this study, they were calculated, before the program started in 2000 and after it ended in 2015, using data from Demographic and Health Surveys and Household Income and Expenditure Surveys, respectively. Using the Composite Coverage Index to measure the effects of the Lymphatic Filariasis Elimination Program revealed that it did not negatively or positively affect health service coverage rates. We can also say that there is a positive association between the program interventions and lowered incidence of catastrophic health expenditures.
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Decouttere C, De Boeck K, Vandaele N. Advancing sustainable development goals through immunization: a literature review. Global Health 2021; 17:95. [PMID: 34446050 PMCID: PMC8390056 DOI: 10.1186/s12992-021-00745-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 07/23/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Immunization directly impacts health (SDG3) and brings a contribution to 14 out of the 17 Sustainable Development Goals (SDGs), such as ending poverty, reducing hunger, and reducing inequalities. Therefore, immunization is recognized to play a central role in reaching the SDGs, especially in low- and middle-income countries (LMICs). Despite continuous interventions to strengthen immunization systems and to adequately respond to emergency immunization during epidemics, the immunization-related indicators for SDG3 lag behind in sub-Saharan Africa. Especially taking into account the current Covid19 pandemic, the current performance on the connected SDGs is both a cause and a result of this. METHODS We conduct a literature review through a keyword search strategy complemented with handpicking and snowballing from earlier reviews. After title and abstract screening, we conducted a qualitative analysis of key insights and categorized them according to showing the impact of immunization on SDGs, sustainability challenges, and model-based solutions to these challenges. RESULTS We reveal the leveraging mechanisms triggered by immunization and position them vis-à-vis the SDGs, within the framework of Public Health and Planetary Health. Several challenges for sustainable control of vaccine-preventable diseases are identified: access to immunization services, global vaccine availability to LMICs, context-dependent vaccine effectiveness, safe and affordable vaccines, local/regional vaccine production, public-private partnerships, and immunization capacity/capability building. Model-based approaches that support SDG-promoting interventions concerning immunization systems are analyzed in light of the strategic priorities of the Immunization Agenda 2030. CONCLUSIONS In general terms, it can be concluded that relevant future research requires (i) design for system resilience, (ii) transdisciplinary modeling, (iii) connecting interventions in immunization with SDG outcomes, (iv) designing interventions and their implementation simultaneously, (v) offering tailored solutions, and (vi) model coordination and integration of services and partnerships. The research and health community is called upon to join forces to activate existing knowledge, generate new insights and develop decision-supporting tools for Low-and Middle-Income Countries' health authorities and communities to leverage immunization in its transformational role toward successfully meeting the SDGs in 2030.
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Affiliation(s)
- Catherine Decouttere
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
| | - Kim De Boeck
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
| | - Nico Vandaele
- KU Leuven, Access-To-Medicines research Center, Naamsestraat 69, Leuven, Belgium
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Cesar JA, Black RE, Buffarini R. Antenatal care in Southern Brazil: Coverage, trends and inequalities. Prev Med 2021; 145:106432. [PMID: 33485999 DOI: 10.1016/j.ypmed.2021.106432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/14/2020] [Accepted: 01/17/2021] [Indexed: 10/22/2022]
Abstract
We described prenatal care quality for four indicators over a 12-years period among puerperae living in Southern Brazil. Five surveys including all women giving birth between 01/01 to 31/12 in 2007, 2010, 2013, 2016, and 2019 were conducted in Rio Grande, Rio Grande do Sul state, Brazil. A single standardized questionnaire was applied within 48 h after delivery in all the city's maternity hospitals. Outcomes included the followings proportion of pregnant women who started prenatal care in the first trimester and performed at least six medical visits, completed at least two HIV, two syphilis and two qualitative urine tests. These indicators were stratified according to quartiles of household income. Absolute and relative measures of inequalities were calculated. A total of 12,645 (98% of the total) of the 12,914 mothers eligible in the five surveys were successfully interviewed. Coverage for all indicators increased substantially, especially in the poorest quartile for six prenatal care visits starting in the first trimester, and for HIV and qualitative urine tests. The slope index (SII) and the concentration index (CIX) of inequality showed clear disadvantage among the poorest for prenatal visits starting in the first trimester and performing two or more urine tests. There was a substantial increase in coverage for all variables studied in the period. The reduced inequity, mainly for the beginning of the first trimester and for visits and urine tests, was due to the higher coverage achieved in the poorest quartile.
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Affiliation(s)
- Juraci A Cesar
- Postgraduate Program in Public Health, Faculty of Medicine, Universidade Federal do Rio Grande, Rua Visconde de Paranaguá, 102, 4th floor, Rio Grande 96210.900, RS, Brazil.
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Romina Buffarini
- Universidade Federal de Pelotas, Marechal Deodoro 1160, 3rd floor, Pelotas, RS 96020-220, Brazil
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Levels of and changes in socioeconomic inequality in delivery care service: A decomposition analysis using Bangladesh Demographic Health Surveys. PLoS One 2020; 15:e0242325. [PMID: 33253221 PMCID: PMC7703934 DOI: 10.1371/journal.pone.0242325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 10/31/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Socioeconomic inequality in maternity care is well-evident in many developing countries including Bangladesh, but there is a paucity of research to examine the determinants of inequality and the changes in the factors of inequality over time. This study examines the factors accounting for the levels of and changes in wealth-related inequality in three outcomes of delivery care service: health facility delivery, skilled birth attendance, and C-section delivery in Bangladesh. METHODS This study uses from the Bangladesh Demographic and Health Survey of 2011 and 2014. We apply logistic regression models to examine the association between household wealth status and delivery care measures, controlling for a wide range of sociodemographic variables. The Erreygers normalised concentration index is used to measure the level of inequalities and decomposition method is applied to disentangle the determinants contributing to the levels of and changes in the observed inequalities. RESULTS We find a substantial inequality in delivery care service utilisation favouring woman from wealthier households. The extent of inequality increased in health facility delivery and C-section delivery in 2014 while increase in skilled birth attendance was not statistically significant. Wealth and education were the main factors explaining both the extent of and the increase in the degree of inequality between 2011 and 2014. Four or more antenatal care (ANC4+) visits accounted for about 8% to 14% of the observed inequality, but the contribution of ANC4+ visits declined in 2014. CONCLUSION This study reveals no progress in equity gain in the use of delivery care services in this decade compared to a declining trend in inequity in the last decade in Bangladesh. Policies need to focus on improving the provision of delivery care services among women from poorer socioeconomic groups. In addition, policy initiatives for promoting the completion of quality education are important to address the stalemate of equity gain in delivery care services in Bangladesh.
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Jolly SP, Chowdhury TR, Rahman M, Alam A, Afsana K. Prevention of social exclusion and role of antenatal care by BRAC community health workers in improving safe motherhood and neonatal care in urban slums of Bangladesh. PLoS One 2020; 15:e0235340. [PMID: 32639998 PMCID: PMC7343159 DOI: 10.1371/journal.pone.0235340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 06/12/2020] [Indexed: 12/05/2022] Open
Abstract
The transformation of the BRAC MANOSHI programme from humanitarian to a social enterprise model, has made it increasingly urgent to enumerate the minimum number of door-to-door antenatal care (ANC) visits by community health workers (CHWs), for the purpose of effectively improving facility delivery. Thus prevent social exclusion of poor slum communities in Bangladesh with regard to safe motherhood and essential newborn care (ENC). This cross-sectional study was conducted, during March–July, 2015 in slums of Chittagong, Dhaka and Sylhet city corporations of Bangladesh. A census was conducted among 25,700 households covering 10 branch offices of MANOSHI to identify women with a delivery outcome in the preceding three years of the survey. A total of 1100 respondents were interviewed randomly through a structured questionnaire. These women were stratified into three categories-1, 2 & 3, consisting of 497, 205 and 398 women respectively. Women in category-1 did not receive any ANC checkup from the BRAC CHWs, while women in category-2 and category-3 received one to three and ≥four ANC checkups from BRAC CHWs respectively. Data was analysed using STATA Version 13 (Chicago Inc.). Findings revealed that women, who received ≥four ANC checkups from BRAC CHWs, are 25% more likely to avail facility delivery [adjusted Prevalence Ratio (aPR) 1.25; 95% confidence interval (CI) (1.01–1.54)] compared to the women who did not receive any ANC from BRAC CHWs. Women in category-2 [aPR3.64; 95% CI (1.76–7.54)] and in category-3 [aPR5.92; 95% CI (3.04–11.53)] respectively had four and six folds higher tendency to receive postnatal care (PNC) within 48 hours after delivery. Furthermore, facility delivery improved PNC assisted by medically trained providers (MTPs) within 48 hours after delivery and ENC in both categories 2 & 3. The evidence shows that at least four ANC visits of BRAC CHWs can increase institutional delivery, and which can further facilitate PNC and ENC visits. At present, the BRAC MANOSHI programme needs to implement feasible strategies to include pregnant women in the slums in receiving at least four ANC checkups by BRAC CHWs for ensuring safe motherhood and newborn care.
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Affiliation(s)
| | | | | | - Ariful Alam
- Health, Nutrition and Population Programme, BRAC, Dhaka, Bangladesh
| | - Kaosar Afsana
- Health, Nutrition and Population Programme, BRAC, Dhaka, Bangladesh
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Albis MLF, Bhadra SK, Chin B. Impact evaluation of contracting primary health care services in urban Bangladesh. BMC Health Serv Res 2019; 19:854. [PMID: 31752843 PMCID: PMC6956513 DOI: 10.1186/s12913-019-4406-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Urban Primary Health Care Project (UPHCP) was implemented by the Government of Bangladesh in response to rapid urbanization and growing inequalities in access to and quality of primary health care. The goal of the project was to improve health status of the urban poor living in city corporations and municipalities through the provision of health care services by NGOs that are contracted through public-private partnership. The first phase of the project started in 1998 and the project is currently in its fourth phase covering more urban areas than the first three phases. This study evaluates the impact of the second phase project (UPHCP-II) on health outcomes, mainly child diarrhea, acute respiratory infection, antenatal and postnatal care, skilled birth attendance, breastfeeding prevalence, contraceptive prevalence, sexually transmitted infections, and HIV/AIDS awareness. METHODS The effect of the project was estimated through propensity score matching between project and non-project areas comparing baseline and endline surveys over a six-year period from 2006 to 2012. An innovation of this study is the recalibration of the sampling weights that allows the use of these two independent surveys in impact evaluation. RESULTS Over the six-year period, UPHCP-II improved the health status of the population in project areas compared to non-project areas. The study found significant improvement in health outcomes in terms of reduced diarrhea and acute respiratory infection in children, which explains the downward trend in child mortality rate. Moreover, the project also improved antenatal care and skilled birth attendance. Contraceptive prevalence and HIV/AIDS awareness and avoidance increased, and sexually transmitted infections decreased. CONCLUSIONS UPHCP-II was effective in achieving its health outcome targets, while previous studies show that it was efficient in the delivery of health care and clients were highly satisfied because health facilities were in close proximity, and doctors and staff were perceived as responsive in delivering high quality of care. The results of this study could help inform future design and implementation of urban health interventions that involve contracting primary health care service delivery in Bangladesh and other similar settings.
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Affiliation(s)
| | - Subrata K Bhadra
- National Institute of Population Research and Training, Dhaka, Bangladesh
| | - Brian Chin
- Asian Development Bank, Manila, Philippines
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Sarker AR, Akram R, Ali N, Sultana M. Coverage and factors associated with full immunisation among children aged 12-59 months in Bangladesh: insights from the nationwide cross-sectional demographic and health survey. BMJ Open 2019; 9:e028020. [PMID: 31289076 PMCID: PMC6629384 DOI: 10.1136/bmjopen-2018-028020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To estimate the coverage and factors associated with full immunisation coverage among children aged 12-59 months in Bangladesh. STUDY DESIGN The study is cross sectional in design. Secondary dataset from Bangladesh Demographic and Health Survey was used for this analysis. Immunisation status was categorised as 'fully immunised' if the children had received all the eight recommended vaccine doses otherwise 'partially/unimmunised'. SETTINGS Bangladesh. PARTICIPANT Children aged 12-59 months were the study participants. Participants were randomly selected through a two-stage stratified sampling design. A total of 6230 children were eligible for the analysis. RESULTS About 86% of the children (5356 out of 6230) were fully immunised. BCG has the highest coverage rate (97.1%) followed by oral polio vaccine 1 (97%) and pentavalent 1 (96.6%), where the coverage rate was the lowest for measles vaccine (88%). Coverage was higher in urban areas (88.5%) when compared with rural ones (85.1%). Full immunisation coverage was significantly higher among children who lived in the Rangpur division (adjusted OR (AOR)=3.46; 95% CI 2.45 to 4.88, p<0.001), were 48-59 months old (AOR=1.32; 95% CI 1.06 to 1.64, p=0.013), lived in a medium size family (AOR=1.56; 95% CI 1.32 to 1.86, p<0.001), had parents with a higher level of education (AOR=1.96; 95% CI 1.21 to 3.17, p=0.006 and AOR=1.55; 95% CI 1.05 to 2.29, p=0.026) and belonged to the richest families (AOR=2.2; 95% CI 1.5 to 3.21, p<0.001). The likelihood of being partially or unimmunised was higher among children who had the father as their sole healthcare decision-maker (AOR=0.69; 95% CI 0.51 to 0.92, p<0.012). CONCLUSIONS There were significant variations of child immunisation coverage across socioeconomic and demographic factors. These findings will inform innovative approaches for immunisation programmes, and the introduction of relevant policies, including regular monitoring and evaluation of immunisation coverage-particularly for low-performing regions, so that the broader benefit of immunisation programmes can be achieved in all strata of the society.
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Affiliation(s)
- Abdur Razzaque Sarker
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
- Bangladesh Institute of Development Studies, Dhaka, Bangladesh
| | - Raisul Akram
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Nausad Ali
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
| | - Marufa Sultana
- International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
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Angdembe MR, Dulal BP, Bhattarai K, Karn S. Trends and predictors of inequality in childhood stunting in Nepal from 1996 to 2016. Int J Equity Health 2019; 18:42. [PMID: 30836975 PMCID: PMC6402091 DOI: 10.1186/s12939-019-0944-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/25/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although decreasing in trend, one-in-three children remain stunted in Nepal and its distribution is unequal among different socioeconomic and geographical subgroups. Thus, it is crucial to assess inequalities in stunting for designing equity focused interventions that target vulnerable groups with higher burden of stunting. This study measures trends and predictors of socioeconomic inequalities in childhood stunting in Nepal. METHODS Data from five rounds (1996-2016) of Nepal Demographic and Health Survey, nationally representative cross-sectional surveys, were used. Levels and trends of absolute and relative disparity in stunting between the poorest and the richest wealth quintiles, and among all quintiles were assessed by calculating absolute and relative difference, concentration curve and index. Average marginal effects of predictors on stunting were calculated using probit regression. The concentration index was subsequently decomposed into contributing factors. RESULTS Even though stunting consistently declined in all wealth quintiles between 1996 and 2016, reduction was relatively higher among the richer quintiles compared to poorer ones. The absolute difference between the poorest and the richest quintile increased from 24.7 in 1996 (64.5% in poorest - 39.8% in richest) to 32.7 percentage points in 2016 (49.2-16.5%). The relative disparity also increased; the ratio of stunting in the poorest to the richest quintile was 1.6 in 1996 and 3.0 in 2016. The concentration index increased (in absolute value) from - 0.078 in 1996 to - 0.147 in 2016 indicating that stunting was disproportionately concentrated in poorer households and socioeconomic inequalities worsened from 1996 to 2016. Decomposition analysis revealed that in 1996, wealth (61%), caste/ethnicity (12%), mother's education (12%) and birth order (9%) were the major contributors to observed socioeconomic inequalities in stunting; while in 2016, wealth (72%), mother's BMI (12%) and birth order (9%) were the major contributors. CONCLUSIONS Despite remarkable improvements in average stunting over the last two decades, substantial socioeconomic inequalities in stunting exists and is determined not only by immediate factors but also by underlying and contextual factors which emphasize the need for coherent actions across different sectors. In addition to reducing inequalities in wealth, nutrition programming should be focused on most disadvantaged subgroups which are prone to both stunting and relative poverty.
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Affiliation(s)
| | | | - Kreepa Bhattarai
- Social Development and Promotion Centre, Sanepa, Lalitpur, Nepal
| | - Sumit Karn
- South Asian Infant Feeding Research Network – Nepal, Kathmandu, Nepal
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Hanifi SMA, Ravn H, Aaby P, Bhuiya A. Where girls are less likely to be fully vaccinated than boys: Evidence from a rural area in Bangladesh. Vaccine 2018; 36:3323-3330. [PMID: 29699785 DOI: 10.1016/j.vaccine.2018.04.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 04/06/2018] [Accepted: 04/19/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Immunization is one of the most successful and effective health intervention to reduce vaccine preventable diseases for children. Recently, Bangladesh has made huge progress in immunization coverage. In this study, we compared the recent immunization coverage between boys and girls in a rural area of Bangladesh. SETTING The study is based on data from Chakaria Health and Demographic Surveillance System (HDSS) of icddr,b, which covers a population of 90,000 individuals living in 16,000 households in 49 villages. METHODS We calculated the coverage of fully immunized children (FIC) for 4584 children aged 12-23 months of age between January 9, 2012 and January 19, 2016. We analyzed immunization coverage using crude FIC coverage ratio (FCR) and adjusted FCR (aFCR) from binary regression models. The dynamic of gender inequality was examined across sociodemographic and economic conditions. MAIN OUTCOME MEASURE The adjusted female/male (F/M) FIC coverage ratios in various sociodemographic and economic categories. RESULTS Among children who lived below the lower poverty line, the F/M aFCR was 0.89 (0.84-0.94) compared to 0.98 (0.95-1.00) for children from the households above lower poverty line (p = 0.003, test for interaction). For children of mothers with no high school education, the F/M aFCR was 0.94 (0.91-0.97), whereas it was 1.00 (0.96-1.04) for children of mothers who attended high school (p = 0.04, test for interaction). The F/M aFCR was 1.01 (0.96-1.06) for first born children but 0.95 (0.93-0.98) for second or higher birth order children (p = 0.04, test for interaction). CONCLUSIONS Fewer girls than boys were completely vaccinated by their first birthday due to girls' lower coverage for measles vaccine. The tendency was most marked for children living below the poverty line, for children whose mothers did not attend high school, and for children of birth order two or higher. In the study setting and similar areas, sex differentials in coverage should be taken into account in ongoing immunization programmes.
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Affiliation(s)
- Syed Manzoor Ahmed Hanifi
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Bangladesh.
| | | | - Peter Aaby
- Bandim Health Project, Apartado 861, Guinea-Bissau
| | - Abbas Bhuiya
- Partners in Population and Development, Bangladesh
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Universal health care in Bangladesh-promises and perils. LANCET GLOBAL HEALTH 2018; 6:e10-e11. [PMID: 29241601 DOI: 10.1016/s2214-109x(17)30470-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 11/01/2017] [Indexed: 11/23/2022]
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Rahman MS, Rahman MM, Gilmour S, Swe KT, Krull Abe S, Shibuya K. Trends in, and projections of, indicators of universal health coverage in Bangladesh, 1995-2030: a Bayesian analysis of population-based household data. LANCET GLOBAL HEALTH 2018; 6:e84-e94. [PMID: 29241620 DOI: 10.1016/s2214-109x(17)30413-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 09/22/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Many countries are implementing health system reforms to achieve universal health coverage (UHC) by 2030. To understand the progress towards UHC in Bangladesh, we estimated trends in indicators of the health service and of financial risk protection. We also estimated the probability of Bangladesh's achieving of UHC targets of 80% essential health-service coverage and 100% financial risk protection by 2030. METHODS We estimated the coverage of UHC indicators-13 prevention indicators and four treatment indicators-from 19 nationally representative population-based household surveys done in Bangladesh from Jan 1, 1991, to Dec 31, 2014. We used a Bayesian regression model to estimate the trend and to predict the coverage of UHC indicators along with the probabilities of achieving UHC targets of 80% coverage of health services and 100% coverage of financial risk protection from catastrophic and impoverishing health payments by 2030. We used the concentration index and relative index of inequality to assess wealth-based inequality in UHC indicators. FINDINGS If the current trends remain unchanged, we estimated that coverage of childhood vaccinations, improved water, oral rehydration treatment, satisfaction with family planning, and non-use of tobacco will achieve the 80% target by 2030. However, coverage of four antenatal care visits, facility-based delivery, skilled birth attendance, postnatal checkups, care seeking for pneumonia, exclusive breastfeeding, non-overweight, and adequate sanitation were not projected to achieve the target. Quintile-specific projections showed wide wealth-based inequality in access to antenatal care, postnatal care, delivery care, adequate sanitation, and care seeking for pneumonia, and this inequality was projected to continue for all indicators. The incidence of catastrophic health expenditure and impoverishment were projected to increase from 17% and 4%, respectively, in 2015, to 20% and 9%, respectively, by 2030. Inequality analysis suggested that wealthiest households would disproportionately face more financial catastrophe than the most disadvantaged households. INTERPRETATION Despite progress, Bangladesh will not achieve the 2030 UHC targets unless the country scales up interventions related to maternal and child health services, and reforms health financing systems to avoid high dependency on out-of-pocket payments. The introduction of a national health insurance system, increased public funding for health care, and expansion of community-based clinics in rural areas could help to move the country towards UHC. FUNDING Japan Ministry of Health, Labour, and Welfare.
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Affiliation(s)
- Md Shafiur Rahman
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Global Public Health Research Foundation, Dhaka, Bangladesh.
| | - Md Mizanur Rahman
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Global Public Health Research Foundation, Dhaka, Bangladesh; Department of Population Science and Human Resource Development, University of Rajshahi, Rajshahi, Bangladesh; Institute for Global Health Policy Research, National Center for Global Health and Medicine, Tokyo, Japan
| | - Stuart Gilmour
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Khin Thet Swe
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Sarah Krull Abe
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kenji Shibuya
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan; Institute for Global Health Policy Research, National Center for Global Health and Medicine, Tokyo, Japan
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Yunus FM, Khan S, Mitra DK, Mistry SK, Afsana K, Rahman M. Relationship of sleep pattern and snoring with chronic disease: findings from a nationwide population-based survey. Sleep Health 2018; 4:40-48. [PMID: 29332678 DOI: 10.1016/j.sleh.2017.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To investigate the association of total sleep time and presence or absence of snoring with chronic disease among the Bangladeshi adult population. DESIGN Cross-sectional survey. SETTING Urban and rural Bangladesh. PARTICIPANTS A total of 12,338 men and women aged ≥35 years. MEASUREMENTS Total sleep time was considered as the total hours of sleep in 24 hours. Furthermore, sleep time was categorized into <7, 7-9, and >9 hours according to National Sleep Foundation (2015) guidelines. Self-reported snoring history was captured and corroborated with their respective sleep partner/spouse in more than 80% cases. Registered physician-diagnosed current and/or previous cases of hypertension, diabetes, coronary heart disease, cancer, stroke, chronic obstructive pulmonary disease, and any other chronic conditions were counted. RESULTS Overall prevalence of at least 1 chronic disease in our study population was around 18%: men (15.4%) and women (20.0%). Hypertension has the highest prevalence (overall: 12.7%, men: 12.2%, women: 15%) followed by diabetes (4.9%), coronary heart diseases (3.2%), stroke (1.8%), chronic obstructive pulmonary disease (0.9%), and cancer (any type: 0.1%). Sleep pattern and snoring are significantly associated with all individual chronic disease except cancer. Sociodemographic, behavioral, and lifestyle variables were adjusted, and inadequate total sleep time (<7 hours) and snoring (yes/no) showed significant association with chronic disease status (risk ratio = 1.11, 95% confidence interval 1.00-1.22 and risk ratio = 1.20, 95% confidence interval 1.11-1.29, respectively). CONCLUSION Inadequate sleep and snoring are independently associated with chronic disease in Bangladeshi adult population and perhaps elsewhere.
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Affiliation(s)
- Fakir Md Yunus
- BRAC Research and Evaluation Division, BRAC Centre, 75 Mohakhali, Dhaka 1212, Bangladesh; College of Pharmacy and Nutrition, The University of Saskatchewan, 104 Clinic Place, Saskatoon SK S7N 2Z4, Saskatchewan, Canada
| | - Safayet Khan
- BRAC Research and Evaluation Division, BRAC Centre, 75 Mohakhali, Dhaka 1212, Bangladesh
| | - Dipak K Mitra
- School of Public Health, Independent University, Bangladesh, Plot 16 Block B, Aftabuddin Ahmed Road, Bashundhara /A, Dhaka, Bangladesh
| | - Sabuj Kanti Mistry
- BRAC Research and Evaluation Division, BRAC Centre, 75 Mohakhali, Dhaka 1212, Bangladesh
| | - Kaosar Afsana
- BRAC Health, Nutrition and Population Program, BRAC Centre, 75 Mohakhali, Dhaka 1212, Bangladesh; James P Grant School of Public Health, BRAC University, 68 ShahidTajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh
| | - Mahfuzar Rahman
- BRAC Research and Evaluation Division, BRAC Centre, 75 Mohakhali, Dhaka 1212, Bangladesh.
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Tahsina T, Ali NB, Hoque DE, Huda TM, Salam SS, Hasan MM, Hossain MA, Matin Z, Kuppen L, Garnett SP, Arifeen SE. Out-of-pocket expenditure for seeking health care for sick children younger than 5 years of age in Bangladesh: findings from cross-sectional surveys, 2009 and 2012. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2017; 36:33. [PMID: 28893323 PMCID: PMC5594455 DOI: 10.1186/s41043-017-0110-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 09/05/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Bangladesh has committed to universal health coverage, and options to decrease household out-of-pocket expenditure (OPE) are being explored. Understanding the determinants of OPE is an essential step. This study aimed to estimate and identify determinants of OPE in seeking health care for sick under-five children. METHODS Cross-sectional data was collected by structured questionnaire in 2009 (n = 7362) and 2012 (n = 6896) from mothers of the under-five children. OPE included consultation fees and costs of medicine, diagnostic tests, hospital admission, transport, accommodation, and food. Expenditure is expressed in US dollars and adjusted for inflation. Linear regression was used for ascertaining the determinants of OPE. RESULTS Between 2009 and 2012, the median OPE for seeking care for a sick under-five child increased by ~ 50%, from USD 0.82 (interquartile range 0.39-1.49) to USD 1.22 (0.63-2.36) per child/visit. Increases were observed in every component OPE measured, except for consultation fees which decreased by 12%. Medicine contributed the major portion of overall OPE. Higher overall OPE for care seeking was associated with a priority illness (20% increase), care from trained providers (90% public/~ 2-fold private), residing in hilly/wet lands areas (20%), and for mothers with a secondary education (19%). CONCLUSION OPE is a major barrier to quality health care services and access to appropriate medicine is increasing in rural Bangladesh. To support the goal of universal health care coverage, geographic imbalances as well as expanded health financing options need to be explored.
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Affiliation(s)
- Tazeen Tahsina
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
| | - Nazia Binte Ali
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
| | | | - Tanvir M. Huda
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
| | | | | | - Md Altaf Hossain
- IMCI, Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare (MOHFW), Dhaka, Bangladesh
| | - Ziaul Matin
- Health Section, UNICEF Bangladesh, Dhaka, Bangladesh
| | - Lianne Kuppen
- Health Section, UNICEF Bangladesh, Dhaka, Bangladesh
| | - Sarah P. Garnett
- The Children’s Hospital at Westmead Clinical School, University of Sydney, Westmead, NSW Australia
| | - Shams El Arifeen
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
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Rahman SM, Kippler M, Tofail F, Bölte S, Hamadani JD, Vahter M. Manganese in Drinking Water and Cognitive Abilities and Behavior at 10 Years of Age: A Prospective Cohort Study. ENVIRONMENTAL HEALTH PERSPECTIVES 2017; 125:057003. [PMID: 28564632 PMCID: PMC5726374 DOI: 10.1289/ehp631] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/08/2016] [Accepted: 06/23/2016] [Indexed: 05/18/2023]
Abstract
BACKGROUND Cross-sectional studies have indicated impaired neurodevelopment with elevated drinking water manganese concentrations (W-Mn), but potential susceptible exposure windows are unknown. OBJECTIVES We prospectively evaluated the effects of W-Mn, from fetal life to school age, on children's cognitive abilities and behavior. METHODS We assessed cognitive abilities and behavior in 1,265 ten-year-old children in rural Bangladesh using the Wechsler Intelligence Scale for Children (WISC-IV) and the Strengths and Difficulties Questionnaire (SDQ), respectively. Manganese in drinking water used during pregnancy and by the children at 5 y and 10 y was measured using inductively coupled plasma mass spectrometry. RESULTS The median W-Mn was 0.20 mg/L (range 0.001–6.6) during pregnancy and 0.34mg/L (<0.001–8.7) at 10 y. In multivariable-adjusted linear regression analyses, restricted to children with low arsenic (As) exposure, none of the W-Mn exposures was associated with the children’s cognitive abilities. Stratifying by gender (p for interaction in general <0.081) showed that prenatal W-Mn (3 mg/L) was positively associated with cognitive ability measures in girls but not in boys. W-Mn at all time points was associated with an increased risk of conduct problems, particularly in boys (range 24–43% per mg/L). At the same time, the prenatal W-Mn was associated with a decreased risk of emotional problems [odds ratio (OR)=0.39 (95% CI: 0.19, 0.82)] in boys. In girls, W-Mn was mainly associated with low prosocial scores [prenatal W-Mn: OR=1.48 (95% CI: 1.06, 1.88)]. CONCLUSIONS Elevated prenatal W-Mn exposure was positively associated with cognitive function in girls, whereas boys appeared to be unaffected. Early life W-Mn exposure appeared to adversely affect children's behavior. https://doi.org/10.1289/EHP631.
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Affiliation(s)
- Syed Moshfiqur Rahman
- Institute of Environmental Medicine, Karolinska Institutet , Stockholm, Sweden
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Maria Kippler
- Institute of Environmental Medicine, Karolinska Institutet , Stockholm, Sweden
| | - Fahmida Tofail
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sven Bölte
- Center of Neurodevelopmental Disorders (KIND), Pediatric Neuropsychiatry Unit, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm County Council, Stockholm, Sweden
| | | | - Marie Vahter
- Institute of Environmental Medicine, Karolinska Institutet , Stockholm, Sweden
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Şimşek Z, Yentur Doni N, Gül Hilali N, Yildirimkaya G. A community-based survey on Syrian refugee women's health and its predictors in Şanliurfa, Turkey. Women Health 2017; 58:617-631. [PMID: 28430082 DOI: 10.1080/03630242.2017.1321609] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Reproductive characteristics, mental health symptoms, micronutrient deficiencies, and symptoms of sexually transmitted infections (STIs) were determined among married Syrian refugee women aged 15-49 years who were living outside of camps in 2015, using probability sampling. Of the 458 participants, 51.3 percent married before the age of 18 years. Early-age marriages and number of desired children increased after the war. In multivariable analyses, education (adjusted odds ratio [aOR] = 1.2; 95% confidence interval [CI] = 1.2-1.3) and length of stay in Şanlıurfa (aOR = 1.2; 95% CI = 1.1-1.2) were independently associated with early marriage. Approximately 16 percent of women were pregnant, and 26.7 percent of them had not received prenatal care; 47.7 percent had had a pregnancy loss; 50.8 percent reported symptoms of STIs. Of those who were sexually active, 37.8 percent were not using contraception. The prevalence of iron, B12, and folic acid deficiencies was 50 percent, 45.6 percent, and 10.5 percent, respectively. Early marriage (aOR = 2.2; 95% CI = 1.4-3.5) and number of desired children (aOR = 5.03; 95% CI = 3.2-7.9) were associated with not using contraception. Most (89.7 percent) women reported at least two mental health symptoms; lack of social support (aOR = 2.6; 95% CI = 1.3-5.3), language barrier (aOR = 2.3; 95% CI = 1.01-5.2), and B12 deficiency (aOR = 1.8; 95% CI = 1.01-3.4) were associated with such symptoms. The findings demonstrate the need for reproductive health and psychosocial services.
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Affiliation(s)
- Zeynep Şimşek
- a Public Health Department, Faculty of Medicine , Harran University , Şanliurfa , Turkey
| | | | - Nese Gül Hilali
- c Gynecology Department, Faculty of Medicine , Harran University , Şanliurfa , Turkey
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Kim C, Saeed KMA, Salehi AS, Zeng W. An equity analysis of utilization of health services in Afghanistan using a national household survey. BMC Public Health 2016; 16:1226. [PMID: 27919238 PMCID: PMC5139141 DOI: 10.1186/s12889-016-3894-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 11/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Afghanistan has made great strides in the coverage of health services across the country but coverage of key indicators remains low nationally and whether the poorest households are accessing these services is not well understood. METHODS We analyzed the Afghanistan Mortality Survey 2010 on utilization of inpatient and outpatient care, institutional delivery and antenatal care by wealth quintiles. Concentration indexes (CIs) were generated to measure the inequality of using the four services. Additional analyses were conducted to examine factors that explain the health inequalities (e.g. age, gender, education and residence). RESULTS Among households reporting utilization of health services, public health facilities were used more often for inpatient care, while they were used less for outpatient care. Overall, the utilization of inpatient and outpatient care, and antenatal care was equally distributed among income groups, with CIs of 0.04, 0.03 and 0.08, respectively. However, the poor used more public facilities while the wealthy used more private facilities. There was a substantial inequality in the use of institutional delivery services, with a CI of 0.31. Poorer women had a lower rate of institutional deliveries overall, in both public and private facilities, compared to the wealthy. Location was an important factor in explaining the inequality in the use of health services. CONCLUSIONS The large gap between the rich and poor in access to and utilization of key maternal services, such as institutional delivery, may be a central factor to the high rates of maternal mortality and morbidity and impedes efforts to make progress toward universal health coverage. While poorer households use public health services more often, the use of public facilities for outpatient visits remains half that of private facilities. Pro-poor targeting as well as a better understanding of the private sector's role in increasing equitable coverage of maternal health services is needed. Equity-oriented approaches in health should be prioritized to promote more inclusive health system reforms.
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Affiliation(s)
- Christine Kim
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | | | | | - Wu Zeng
- Schneider Institutes for Health Policy, Heller School, Brandeis University, MS 035, Waltham, MA 02454 USA
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Rabbani A, Khan A, Yusuf S, Adams A. Trends and determinants of inequities in childhood stunting in Bangladesh from 1996/7 to 2014. Int J Equity Health 2016; 15:186. [PMID: 27852266 PMCID: PMC5112749 DOI: 10.1186/s12939-016-0477-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We explore long-term trends and determinants of socioeconomic inequities in chronic childhood undernutrition measured by stunting among under-five children in Bangladesh. Given that one in three children remain stunted in Bangladesh, the socioeconomic mapping of stunting prevalence may be critical in designing public policies and interventions to eradicate childhood undernutrition. METHODS Six rounds of Bangladesh Demographic and Health Survey data are utilized, spanning the period 1996/97 to 2014. Using recognized measures of absolute and relative inequality (namely, absolute and relative difference, concentration curve and index), we quantify trends, and decompose changes in the concentration index to identify factors that best explain observed dynamics. RESULTS Despite remarkable improvements in average nutritional status over the last two decades, socio-economic inequalities have persisted, and according to some measures, even worsened. For example, expressed as rate-ratios, the relative inequality in under-five stunting increased by 56% and the concentration index more than doubled between 1996/97 and 2014. Decomposition analyses find that wealth and maternal factors such as mothers' schooling and short stature are major contributors to observed socio-economic inequalities in child undernutrition and their changes over time. CONCLUSIONS Reflecting on recent success around socioeconomic and gender equity in child mortality, and the weak legacy of nutrition policy in Bangladesh, we suggest that nutrition programming energies be focused specifically on the most disadvantaged and applied at scale to close socioeconomic gaps in stunting prevalence.
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Affiliation(s)
- Atonu Rabbani
- Department of Economics, University of Dhaka, Dhaka, Bangladesh
| | - Akib Khan
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh.
| | - Sifat Yusuf
- Health Systems and Population Sciences Division, International Center for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Alayne Adams
- Health Systems and Population Sciences Division, International Center for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh
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Evaluation of Maternal Health Service Indicators in Urban Slum of Bangladesh. PLoS One 2016; 11:e0162825. [PMID: 27732596 PMCID: PMC5061363 DOI: 10.1371/journal.pone.0162825] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 08/29/2016] [Indexed: 11/29/2022] Open
Abstract
Background A continuous influx of poor people to urban slums poses a challenge to Bangladesh’s health system as it has failed to tackle maternal morbidity and mortality. BRAC is the largest non-governmental organisation in Bangladesh. BRAC has been working to reduce maternal, neonatal and under-five children morbidity and mortality of slum dwellers in cities. BRAC has been doing this work for a decade through a programme called MANOSHI. This programme provides door-to-door services to its beneficiaries through community health workers (CHWs) and normal delivery service through its delivery and maternity centres. BRAC started the ‘MANOSHI’ programme in Narayanganj City Corporation during 2011 to address maternal, neonatal and child health problems facing slum dwellers. We investigated the existing maternal health-service indicators in the slums of Narayanganj City Corporation and compared the findings with a non-intervention area. Methods This cross-sectional study was conducted during 2012, in 47 slums of Narayanganj City Corporation as intervention and 10 slums of Narsingdi Sadar Municipality as comparison area. A total of 1206 married women, aged 15–49 years, with a pregnancy outcome in the previous year were included for interview. Data on socio-demographic characteristics, reproductive and maternal health-care practices like use of contraceptive methods, antenatal care (ANC), delivery care, postnatal care (PNC) were collected through a structured questionnaire. The chi-square test, Student t test, Mann Whitney U-test, factor analysis and log-binominal test were performed by using STATA statistical software for analysing data. Results The activities of BRAC CHWs significantly improved four or more ANC (47% vs. 21%; p<0.000) and PNC (48% vs. 39%; p<0.01) coverage in the intervention slums compared to comparison slums. Still, about half of the deliveries in both areas were attended at home by unskilled birth attendants, of which a very few received PNC within 48 hours after delivery. The poorest and illiterate women received fewer maternal health services from medically trained providers (MTPs). The poorest had a lower likelihood of receiving services from MTPs during delivery complications. Conclusion The MANOSHI programme service coverage for delivery care and PNC-checkup for women who prefer home delivery needs to be improved. For sustainable improvement of maternal health outcomes in urban slums, the programme needs to facilitate access to services for poor and illiterate women.
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Hasman A, Noble DJ. Childhood immunisation in South Asia - overcoming the hurdles to progress. Perspect Public Health 2016; 136:273-7. [PMID: 27528641 PMCID: PMC4989267 DOI: 10.1177/1757913916658633] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Pulok MH, Sabah MNU, Uddin J, Enemark U. Progress in the utilization of antenatal and delivery care services in Bangladesh: where does the equity gap lie? BMC Pregnancy Childbirth 2016; 16:200. [PMID: 27473150 PMCID: PMC4967314 DOI: 10.1186/s12884-016-0970-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 07/14/2016] [Indexed: 11/26/2022] Open
Abstract
Background Universal access to health care services does not automatically guarantee equity in the health system. In the post Millennium Development Goals (MDGs) era, the progress towards universal access to maternal health care services in a developing country, like Bangladesh requires an evaluation in terms of equity lens. This study, therefore, analysed the trend in inequity and identified the equity gap in the utilization of antenatal care (ANC) and delivery care services in Bangladesh between 2004 and 2011. Methods The data of this study came from the Bangladesh Demographic and Health Survey. We employed rate ratio, concentration curve and concentration index to examine the trend in inequity of ANC and delivery care services. We also used logistic regression models to analyse the relationship between socioeconomic factors and maternal health care services. Results The concentration index for 4+ ANC visits dropped from 0.42 in 2004 to 0.31 in 2011 with a greater decline in urban area. There was almost no change in the concentration index for ANC services from medically trained providers during this period. We also found a decreasing trend in inequity in the utilization of both health facility delivery and skilled birth assistance but this trend was again more pronounced in urban area compared to rural area. The concentration index for C-section delivery decreased by about 33 % over 2004–2011 with a similar rate in both urban and rural areas. Women from the richest households were about 3 times more likely to have 4+ ANC visits, delivery at a health facility and skilled birth assistance compared to women from the poorest households. Women’s and their husbands’ education were significantly associated with greater use of maternal health care services. In addition, women’s exposure to mass media, their involvement in microcredit programs and autonomy in healthcare decision-making appeared as significant predictors of using some of these health care services. Conclusions Bangladesh faces not only a persistent pro-rich inequity but also a significant rural-urban equity gap in the uptake of maternal health care services. An equity perspective in policy interventions is much needed to ensure safe motherhood and childbirth in Bangladesh.
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Affiliation(s)
- Mohammad Habibullah Pulok
- Department of Economics, Southeast University, Dhaka, Bangladesh. .,Centre for Health Economics Research and Evaluation (CHERE), University of Technology, Sydney (UTS), Sydney, Australia.
| | - Md Nasim-Us Sabah
- Department of Finance, Rawls College of Business, Texas Tech University, Lubbock, USA
| | - Jalal Uddin
- Department of Sociology, University of Alabama at Birmingham, Birmingham, USA
| | - Ulrika Enemark
- Department of Public Health, Aarhus University, Aarhus, Denmark
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McDougal L, Rusch ML, Silverman JG, Raj A. Linkages Within the Reproductive and Maternal Health Continuum of Care in Bangladesh. Asia Pac J Public Health 2016; 28:423-37. [PMID: 27371578 DOI: 10.1177/1010539516654539] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The continuum of care (CoC) is a fundamental approach to reproductive, maternal, newborn, and child health policy and programs, but linkages along the CoC are inadequately understood. This article assesses linkages in reproductive and maternal health (RMH) services in Bangladesh using the 2011 Bangladesh Demographic and Health Survey (n = 7170). Antenatal care (ANC) was positively associated with skilled birth attendance (SBA) among both pre-pregnancy contraceptive users and nonusers. Among women who used pre-pregnancy contraceptives but did not receive skilled ANC, there was a 26% decreased odds of SBA. Pre-pregnancy contraceptive use increased the odds of postpartum contraceptive use, but neither ANC nor SBA was associated with postpartum contraceptive use. There are clear linkages within maternal health services and within reproductive health services, but linkages across life stages were variable. Removing barriers to accessing health services early and addressing barriers in the transitions within RMH care will facilitate sustained engagement along the CoC.
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Affiliation(s)
- Lotus McDougal
- Center on Gender Equity and Health, Division of Global Public Health, University of California, San Diego, California, USA
| | | | - Jay G. Silverman
- Center on Gender Equity and Health, Division of Global Public Health, University of California, San Diego, California, USA
| | - Anita Raj
- Center on Gender Equity and Health, Division of Global Public Health, University of California, San Diego, California, USA
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Arku RE, Bennett JE, Castro MC, Agyeman-Duah K, Mintah SE, Ware JH, Nyarko P, Spengler JD, Agyei-Mensah S, Ezzati M. Geographical Inequalities and Social and Environmental Risk Factors for Under-Five Mortality in Ghana in 2000 and 2010: Bayesian Spatial Analysis of Census Data. PLoS Med 2016; 13:e1002038. [PMID: 27327774 PMCID: PMC4915620 DOI: 10.1371/journal.pmed.1002038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 04/21/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Under-five mortality is declining in Ghana and many other countries. Very few studies have measured under-five mortality-and its social and environmental risk factors-at fine spatial resolutions, which is relevant for policy purposes. Our aim was to estimate under-five mortality and its social and environmental risk factors at the district level in Ghana. METHODS AND FINDINGS We used 10% random samples of Ghana's 2000 and 2010 National Population and Housing Censuses. We applied indirect demographic methods and a Bayesian spatial model to the information on total number of children ever born and children surviving to estimate under-five mortality (probability of dying by 5 y of age, 5q0) for each of Ghana's 110 districts. We also used the census data to estimate the distributions of households or persons in each district in terms of fuel used for cooking, sanitation facility, drinking water source, and parental education. Median district 5q0 declined from 99 deaths per 1,000 live births in 2000 to 70 in 2010. The decline ranged from <5% in some northern districts, where 5q0 had been higher in 2000, to >40% in southern districts, where it had been lower in 2000, exacerbating existing inequalities. Primary education increased in men and women, and more households had access to improved water and sanitation and cleaner cooking fuels. Higher use of liquefied petroleum gas for cooking was associated with lower 5q0 in multivariate analysis. CONCLUSIONS Under-five mortality has declined in all of Ghana's districts, but the cross-district inequality in mortality has increased. There is a need for additional data, including on healthcare, and additional environmental and socioeconomic measurements, to understand the reasons for the variations in mortality levels and trends.
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Affiliation(s)
- Raphael E. Arku
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - James E. Bennett
- MRC-PHE Centre for Environment and Health, Imperial College London, London, United Kingdom
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Marcia C. Castro
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | | | | | - James H. Ware
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | | | - John D. Spengler
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Samuel Agyei-Mensah
- Department of Geography and Resource Development, University of Ghana, Legon, Ghana
| | - Majid Ezzati
- MRC-PHE Centre for Environment and Health, Imperial College London, London, United Kingdom
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
- Wellcome Trust Centre for Global Health Research, Imperial College London, London, United Kingdom
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Neonatal Mortality and Inequalities in Bangladesh: Differential Progress and Sub-national Developments. Matern Child Health J 2016; 19:2038-47. [PMID: 25652066 DOI: 10.1007/s10995-015-1716-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A rapid reduction in under-five mortality has put Bangladesh on-track to reach Millennium Development Goal 4. Little research, however, has been conducted into neonatal reductions and sub-national rates in the country, with considerable disparities potentially masked by national reductions. The aim of this paper is to estimate national and sub-national rates of neonatal mortality to compute relative and absolute inequalities between sub-national groups and draw comparisons with rates of under-five mortality. Mortality rates for under-five children and neonates were estimated directly for 1980-1981 to 2010-2011 using data from six waves of the Demographic and Health Survey. Rates were stratified by levels of rural/urban location, household wealth and maternal education. Absolute and relative inequalities within these groups were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. National mortality was shown to have decreased dramatically although at differential rates for under-fives and neonates. Across all equity markers, a general pattern of declining absolute but constant relative inequalities was found. For mortality rates stratified by education and wealth mixed evidence suggests that relative inequalities may have also fallen. Although disparities remain, Bangladesh has achieved a rare combination of substantive reductions in mortality levels without increases in relative inequalities. A coalescence of substantial increases in coverage and equitable distribution of key child and neonatal interventions with widespread health sectoral and policy changes over the last 30 years may in part explain this exceptional pattern.
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Rousham EK, Khandakar IU. Reducing health inequalities among girls and adolescent women living in poverty: the success of Bangladesh. Ann Hum Biol 2016; 43:115-21. [PMID: 26769318 DOI: 10.3109/03014460.2016.1141985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Bangladesh has made dramatic improvements in the health of girls and women in the last 20 years. This paper examines whether gender inequalities in health are evident among older children and adolescents among extremely poor households and identifies future health challenges for improving the health of girls and women. SUBJECTS AND METHODS Gender inequalities in health were examined using data from a school health survey of school children and adolescents (n = 900, 6.5-13.5 years). Anthropometric status, household possessions and number of siblings were measured. Under-nutrition was assessed as stunting (height-for-age z-score) and thinness (BMI-for-age z-score). RESULTS The prevalence of under-nutrition was high (35.3% stunting; 42.4% thinness), but there were no significant differences according to gender or socio-economic indicators (via possession score). Girls had more younger siblings (p < 0.05), while boys had more older siblings (p < 0.05). CONCLUSIONS These findings accord with the national picture of successful reductions in gender inequalities in health through low cost, community-based health programmes and education policies targeting the poorest sectors. The prevalence of under-nutrition, however, remains high. Reproductive behaviours may still be influenced by poverty and the gender of existing offspring. Future challenges lie in reducing the adverse health consequences to women and their infants associated with early age at marriage and childbirth.
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Affiliation(s)
- Emily K Rousham
- a Centre for Global Health and Human Development, School of Sport, Exercise and Health Sciences, Loughborough University , Loughborough , Leicestershire LE11 3TU , UK
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Huda TM, Tahsina T, El Arifeen S, Dibley MJ. The importance of intersectoral factors in promoting equity-oriented universal health coverage: a multilevel analysis of social determinants affecting neonatal infant and under-five mortality in Bangladesh. Glob Health Action 2016; 9:29741. [PMID: 26880153 PMCID: PMC4754013 DOI: 10.3402/gha.v9.29741] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 12/13/2015] [Accepted: 12/15/2015] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Health is multidimensional and affected by a wide range of factors, many of which are outside the health sector. To improve population health and reduce health inequality, it is important that we take into account the complex interactions among social, environmental, behavioural, and biological factors and design our health interventions accordingly. OBJECTIVES This study examines mortality differentials in children of different age groups by key social determinants of health (SDH) including parental education and employment, mother's level of autonomy, age, asset index, living arrangements (utilities), and other geographical contextual factors (area of residence, road conditions). DESIGN We used data from the two rounds of Bangladesh Health and Demographic Survey, a nationally representative sample survey of the population residing in Bangladesh. Multilevel logistic models were used to study the impact of SDH on child mortality. RESULTS The study found that the mother's age, the education of both parents, the mother's autonomy to take decisions about matters linked to the health of her child, the household socio-economic conditions, the geographical region of residence, and the condition of the roads were significantly associated with higher risks of neonatal, infant, and under-five mortality in Bangladesh. CONCLUSION The study findings suggest there are complex relationships among different SDH. Thus larger intersectoral actions will be needed to reduce disparities in child health and mortality and achieve meaningful progress towards equity-oriented universal health coverage.
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Affiliation(s)
- Tanvir M Huda
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh; ;
| | - Tazeen Tahsina
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - Shams El Arifeen
- Centre for Child and Adolescent Health, icddr,b, Dhaka, Bangladesh
| | - Michael J Dibley
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
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Theobald S, MacPherson E, McCollum R, Tolhurst R. Close to community health providers post 2015: Realising their role in responsive health systems and addressing gendered social determinants of health. BMC Proc 2015; 9:S8. [PMID: 28281706 PMCID: PMC4699124 DOI: 10.1186/1753-6561-9-s10-s8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Universal health coverage is gaining momentum and is likely to form a core part of the post Millennium Development Goal (MDG) agenda and be linked to social determinants of health, including gender; Close to community health providers are arguably key players in meeting the goal of universal health coverage through extending and delivering health services to poor and marginalised groups; Close to community health providers are embedded in communities and may therefore be strategically placed to understand intra household gender and power dynamics and how social determinants shape health and well-being. However, the opportunities to develop critical awareness and to translate this knowledge into health system and multi-sectoral action are poorly understood; Enabling close to community health providers to realise their potential requires health systems support and human resource management at multiple levels.
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Affiliation(s)
- Sally Theobald
- International Public Health Department, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Eleanor MacPherson
- International Public Health Department, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Rosalind McCollum
- International Public Health Department, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Rachel Tolhurst
- International Public Health Department, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
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Anwar I, Nababan HY, Mostari S, Rahman A, Khan JAM. Trends and inequities in use of maternal health care services in Bangladesh, 1991-2011. PLoS One 2015; 10:e0120309. [PMID: 25799500 PMCID: PMC4370698 DOI: 10.1371/journal.pone.0120309] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 12/18/2014] [Indexed: 11/18/2022] Open
Abstract
Background and Methods Monitoring use-inequity is important to measure progress in efforts to address health-inequities. Using data from six Bangladesh Demographic and Health Surveys (BDHS), we examine trends, inequities and socio-demographic determinants of use of maternal health care services in Bangladesh between 1991 and 2011. Findings Access to maternal health care services has improved in the last two decades. The adjusted yearly trend was 9.0% (8.6%-9.5%) for any antenatal care (ANC), 11.9% (11.1%-12.7%) for institutional delivery, and 18.9% (17.3%-20.5%) for C-section delivery which is above the WHO recommended rate of 5-15%. Use-inequity was significant for all three indicators but is reducing over time. Between 1991-1994 and 2007-2011 the rich:poor ratio reduced from 3.65 to 1.65 for ANC and from 15.80 to 6.77 for institutional delivery. Between 1995-1998 and 2007-2011, the concentration index reduced from 0.27 (0.25-0.29) to 0.15 (0.14-0.16) for ANC, and from 0.65 (0.60-0.71) to 0.39 (0.37-0.41) for institutional delivery during that period. For use of c-section, the rich:poor ratio reduced from 18.17 to 13.39 and the concentration index from 0.66 (0.57-0.75) to 0.47 (0.45-0.49). In terms of rich:poor differences, there was equity-gain for ANC but not for facility delivery or C-section delivery. All socio-demographic variables were significant predictors of use; of them, maternal education was the most powerful. In addition, the contribution of for-profit private sector is increasingly growing in maternal health. Conclusion Both access and equity are improving in maternal health. We recommend strengthening ongoing health and non-health interventions for the poor. Use-inequity should be monitored using multiple indicators which are incorporated into routine health information systems. Rising C-section rate is alarming and indication of C-sections should be monitored both in private and public sector facilities.
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Affiliation(s)
- Iqbal Anwar
- International Centre for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh
- * E-mail:
| | - Herfina Y. Nababan
- International Centre for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Shabnam Mostari
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Aminur Rahman
- International Centre for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh
| | - Jahangir A. M. Khan
- International Centre for Diarrheal Disease Research (icddr,b), Dhaka, Bangladesh
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Abstract
The first Millennium Development Goal (MDG 1) due in 2015 concerns poverty reduction. It has been claimed to be fulfilled on a global level, but still more than 1 billion people are living in abject poverty. There is a strong link between the economy and child survival, and only a minority of countries will have reached the MDG target for child mortality reduction by 2015. This paper discusses the relationship between poverty and child survival. It argues that a focus on equity is necessary to further reduce child mortality, through poverty reduction in absolute terms and also through targeting interventions for increased child survival to disadvantaged populations. The political will to actually achieve real change for those in greatest need is crucial but not to be taken for granted, and the distribution rather than the generation of wealth needs to be made a priority in the post-MDG era.
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Hanifi SMA, Mahmood SS, Bhuiya A. Cause-specific mortality and socioeconomic status in Chakaria, Bangladesh. Glob Health Action 2014; 7:25473. [PMID: 25377331 PMCID: PMC4220129 DOI: 10.3402/gha.v7.25473] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/12/2014] [Accepted: 09/12/2014] [Indexed: 11/20/2022] Open
Abstract
Background Bangladesh has achieved remarkable gains in health indicators during the last four decades despite low levels of economic development. However, the persistence of inequities remains disturbing. This success was also accompanied by health and demographic transitions, which in turn brings new challenges for a nation that has yet to come to terms with pre-transition health challenges. It is therefore important to understand the causes of death and their relationship with socioeconomic status (SES). Objective The paper aims to assess the causes of death by SES based on surveillance data from a rural area of Bangladesh, in order to understand the situation and inform policy makers and programme leaders. Design We analysed population-based mortality data collected from the Chakaria Health and Demographic Surveillance System in Bangladesh. The causes of death were determined by using a Bayesian-based programme for interpreting verbal autopsy findings (InterVA-4). The data included 1,391 deaths in 217,167 person-years of observation between 2010 and 2012. The wealth index constructed using household assets was used to assess the SES, and disease burdens were compared among the wealth quintiles. Results Analysing cause of death (CoD) revealed that non-communicable diseases (NCDs) were the leading causes of deaths (37%), followed by communicable diseases (CDs) (22%), perinatal and neonatal conditions (11%), and injury and accidents (6%); the cause of remaining 24% of deaths could not be determined. Age-specific mortality showed premature birth, respiratory infections, and drowning were the dominant causes of death for childhood mortality (0–14 years), which was inversely associated with SES (p<0.04). For adult and the elderly (15 years and older), NCDs were the leading cause of death (51%), followed by CDs (23%). For adult and the elderly, NCDs concentrated among the population from higher SES groups (p<0.005), and CDs among the lower SES groups (p<0.001). Conclusions Epidemiologic transition is taking place with a shift from the dominance of CDs to NCDs. SES inequity in mortality still persists – the poor suffer from CDs in all age groups, whereas those better off suffer more from NCDs than CDs. Policy makers thus need to consider the social distribution of diseases before developing any public health action targeted towards reducing mortality and the extent of disease burden in an equitable manner.
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Affiliation(s)
- Syed M A Hanifi
- INDEPTH Network, Accra, Ghana; Centre for Equity and Health Systems, ICDDR,B, Dhaka, Bangladesh;
| | - Shehrin S Mahmood
- INDEPTH Network, Accra, Ghana; Centre for Equity and Health Systems, ICDDR,B, Dhaka, Bangladesh
| | - Abbas Bhuiya
- INDEPTH Network, Accra, Ghana; Centre for Equity and Health Systems, ICDDR,B, Dhaka, Bangladesh
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Affiliation(s)
- Joy E Lawn
- London School Hygiene & Tropical Medicine, London WC1E 7HT, UK.
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Huda T, Khan JAM, Ahsan KZ, Jamil K, Arifeen SE. Monitoring and evaluating progress towards Universal Health Coverage in Bangladesh. PLoS Med 2014; 11:e1001722. [PMID: 25244599 PMCID: PMC4170958 DOI: 10.1371/journal.pmed.1001722] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Tanvir Mahmudul Huda and colleagues illustrate progress towards UHC and its monitoring and evaluation in Bangladesh. Please see later in the article for the Editors' Summary
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Affiliation(s)
- Tanvir Huda
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, Australia
- * E-mail: ;
| | - Jahangir A. M. Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
| | - Karar Zunaid Ahsan
- MEASURE Evaluation, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Kanta Jamil
- United States Agency for International Development/Bangladesh, Dhaka, Bangladesh
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
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Hossain MS, Ferdous S, Karim-Kos HE. Breast cancer in South Asia: a Bangladeshi perspective. Cancer Epidemiol 2014; 38:465-70. [PMID: 25182670 DOI: 10.1016/j.canep.2014.08.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/13/2014] [Accepted: 08/03/2014] [Indexed: 11/19/2022]
Abstract
South Asian countries are facing a hidden breast cancer epidemic. A significant proportion of the breast cancer cases occur in premenopausal women. Knowledge of the various aspects of breast cancer in different geographical regions is limited in South Asia. In this article, we review the Bangladeshi perspective of the epidemiology, risk factors, pathology, diagnosis and treatment of breast cancer. As in other developing countries, because of the lack of breast cancer awareness in Bangladeshi population and inadequate access to health care, most patients are diagnosed at an advanced stage of the disease. Early detection has a crucial impact on overall treatment outcomes. To battle against breast cancer in resource-limited countries like Bangladesh, it is not feasible to set up a parallel health service system solely dedicated to cancer. Therefore, a cost-effective public health strategy is needed which could reach a large number of women in the country. Considering all these issues, we propose an innovative female-based primary healthcare approach focused on awareness, screening and early detection of breast cancer in Bangladesh. This preventive strategy could be a model for other resource-limited developing countries.
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Affiliation(s)
- Mohammad Sorowar Hossain
- BRAC University, Department of Mathematical and Natural Sciences, Dhaka, Bangladesh; Biotechnology Division, Incepta Pharmaceutical Ltd, Dhaka, Bangladesh.
| | | | - Henrike E Karim-Kos
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
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Mbizvo MT, Phillips SJ. Family planning: choices and challenges for developing countries. Best Pract Res Clin Obstet Gynaecol 2014; 28:931-43. [PMID: 24957693 DOI: 10.1016/j.bpobgyn.2014.04.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 04/22/2014] [Accepted: 04/25/2014] [Indexed: 10/25/2022]
Abstract
While slow and uneven progress has been made on maternal health, attaining the 1994 Cairo International Conference on Population and Development (ICPD) goal for achieving universal access to reproductive health remains elusive for many developing countries. Assuring access to sexual and reproductive health services, including integrated family planning services, remains a critical strategy for improving the health and well-being of women and alleviating poverty. Family planning not only prevents maternal, infant, and child deaths, but also empowers women to engage fully in socioeconomic development and provides them with reproductive choices. This paper will discuss the current landscape of contraception in developing countries, including options available to women and couples, as well as the challenges to its provision. Finally, we review suggestions to improve access and promising strategies to ensure all people have universal access to reproductive health options.
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Affiliation(s)
- Michael T Mbizvo
- Department of Obstetrics and Gynaecology, University of Zimbabwe, College of Health Sciences, Zimbabwe.
| | - Sharon J Phillips
- Department of Reproductive Health and Research, World Health Organization, Switzerland
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Pagel C, Prost A, Hossen M, Azad K, Kuddus A, Roy SS, Nair N, Tripathy P, Saville N, Sen A, Sikorski C, Manandhar DS, Costello A, Crowe S. Is essential newborn care provided by institutions and after home births? Analysis of prospective data from community trials in rural South Asia. BMC Pregnancy Childbirth 2014; 14:99. [PMID: 24606612 PMCID: PMC4016384 DOI: 10.1186/1471-2393-14-99] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 02/24/2014] [Indexed: 11/10/2022] Open
Abstract
Background Provision of essential newborn care (ENC) can save many newborn lives in poor resource settings but coverage is far from universal and varies by country and place of delivery. Understanding gaps in current coverage and where coverage is good, in different contexts and places of delivery, could make a valuable contribution to the future design of interventions to reduce neonatal mortality. We sought to describe the coverage of essential newborn care practices for births in institutions, at home with a skilled birth attendant, and at home without a skilled birth attendant (SBA) in rural areas of Bangladesh, Nepal, and India. Methods We used data from the control arms of four cluster randomised controlled trials in Bangladesh, Eastern India and from Makwanpur and Dhanusha districts in Nepal, covering periods from 2001 to 2011. We used these data to identify essential newborn care practices as defined by the World Health Organization. Each birth was allocated to one of three delivery types: home birth without an SBA, home birth with an SBA, or institutional delivery. For each study, we calculated the observed proportion of births that received each care practice by delivery type with 95% confidence intervals, adjusted for clustering and, where appropriate, stratification. Results After exclusions, we analysed data for 8939 births from Eastern India, 27 553 births from Bangladesh, 6765 births from Makwanpur and 15 344 births from Dhanusha. Across all study areas, coverage of essential newborn care practices was highest in institutional deliveries, and lowest in home non-SBA deliveries. However, institutional deliveries did not provide universal coverage of the recommended practices, with relatively low coverage (20%-70%) across all study areas for immediate breastfeeding and thermal care. Institutions in Bangladesh had the highest coverage for almost all care practices except thermal care. Across all areas, fewer than 20% of home non-SBA deliveries used a clean delivery kit, the use of plastic gloves was very low and coverage of recommended thermal care was relatively poor. There were large differences between study areas in handwashing, immediate breastfeeding and delayed bathing. Conclusions There remains substantial scope for health facilities to improve thermal care for the newborn and to encourage immediate and exclusive breastfeeding. For unattended home deliveries, increased handwashing, use of clean delivery kits and basic thermal care offer great scope for improvement.
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Affiliation(s)
- Christina Pagel
- Clinical Operational Research Unit, University College London, 4 Taviton Street, London WC1H 0BT, UK.
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Davis R. 2013, a very good year. Pan Afr Med J 2014; 17:72. [PMID: 25018822 PMCID: PMC4085938 DOI: 10.11604/pamj.2014.17.72.3918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 01/30/2014] [Indexed: 11/11/2022] Open
Affiliation(s)
- Robert Davis
- American Red Cross, International Services, Nairobi, Kenya
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Cash RA, Halder SR, Husain M, Islam MS, Mallick FH, May MA, Rahman M, Rahman MA. Reducing the health effect of natural hazards in Bangladesh. Lancet 2013; 382:2094-103. [PMID: 24268610 DOI: 10.1016/s0140-6736(13)61948-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Bangladesh, with a population of 151 million people, is a country that is particularly prone to natural disasters: 26% of the population are affected by cyclones and 70% live in flood-prone regions. Mortality and morbidity from these events have fallen substantially in the past 50 years, partly because of improvements in disaster management. Thousands of cyclone shelters have been built and government and civil society have mobilised strategies to provide early warning and respond quickly. Increasingly, flood and cyclone interventions have leveraged community resilience, and general activities for poverty reduction have integrated disaster management. Furthermore, overall population health has improved greatly on the basis of successful public health activities, which has helped to mitigate the effect of natural disasters. Challenges to the maintenance and reduction of the effect of cyclones and floods include rapid urbanisation and the growing effect of global warming. Although the effects of earthquakes are unknown, some efforts to prepare for this type of event are underway.
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Affiliation(s)
- Richard A Cash
- Public Health Foundation of India, New Delhi, India; Harvard School of Public Health, Boston, MA, USA
| | - Shantana R Halder
- Comprehensive Disaster Management Programme, Government of Bangladesh, Disaster Management and Relief Bhaban, Dhaka, Bangladesh
| | - Mushtuq Husain
- Institute of Epidemiology and Disease Control Research, Dhaka, Bangladesh
| | - Md Sirajul Islam
- Environmental Microbiology Laboratory, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Fuad H Mallick
- Postgraduate Programs in Disaster Management, Department of Architecture, BRAC University, Dhaka, Bangladesh
| | - Maria A May
- Social Innovation Lab, BRAC, BRAC Center, Dhaka, Bangladesh.
| | - Mahmudur Rahman
- Institute of Epidemiology and Disease Control Research, Dhaka, Bangladesh
| | - M Aminur Rahman
- Postgraduate Programs in Disaster Management, Department of Architecture, BRAC University, Dhaka, Bangladesh
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Adams AM, Ahmed T, El Arifeen S, Evans TG, Huda T, Reichenbach L. Innovation for universal health coverage in Bangladesh: a call to action. Lancet 2013; 382:2104-11. [PMID: 24268605 DOI: 10.1016/s0140-6736(13)62150-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A post-Millennium Development Goals agenda for health in Bangladesh should be defined to encourage a second generation of health-system innovations under the clarion call of universal health coverage. This agenda should draw on the experience of the first generation of innovations that underlie the country's impressive health achievements and creatively address future health challenges. Central to the reform process will be the development of a multipronged strategic approach that: responds to existing demands in a way that assures affordable, equitable, high-quality health care from a pluralistic health system; anticipates health-care needs in a period of rapid health and social transition; and addresses underlying structural issues that otherwise might hamper progress. A pragmatic reform agenda for achieving universal health coverage in Bangladesh should include development of a long-term national human resources policy and action plan, establishment of a national insurance system, building of an interoperable electronic health information system, investment to strengthen the capacity of the Ministry of Health and Family Welfare, and creation of a supraministerial council on health. Greater political, financial, and technical investment to implement this reform agenda offers the prospect of a stronger, more resilient, sustainable, and equitable health system.
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Affiliation(s)
- Alayne M Adams
- Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
| | - Tanvir Ahmed
- Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Shams El Arifeen
- Centre for Child Health and Adolescent Health, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Tanvir Huda
- Centre for Child Health and Adolescent Health, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Laura Reichenbach
- Centre for Reproductive Health, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Affiliation(s)
- Amartya Sen
- Department of Economics, Harvard University, Littauer Center, Cambridge, MA 02138, USA.
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Chowdhury AMR, Bhuiya A, Chowdhury ME, Rasheed S, Hussain Z, Chen LC. The Bangladesh paradox: exceptional health achievement despite economic poverty. Lancet 2013; 382:1734-45. [PMID: 24268002 DOI: 10.1016/s0140-6736(13)62148-0] [Citation(s) in RCA: 191] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Bangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the country's success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Government and non-governmental organisations have pioneered many innovations that have been scaled up nationally. However, these remarkable achievements in equity and coverage are counterbalanced by the persistence of child and maternal malnutrition and the low use of maternity-related services. The Bangladesh paradox shows the net outcome of successful direct health action in both positive and negative social determinants of health--ie, positives such as women's empowerment, widespread education, and mitigation of the effect of natural disasters; and negatives such as low gross domestic product, pervasive poverty, and the persistence of income inequality. Bangladesh offers lessons such as how gender equity can improve health outcomes, how health innovations can be scaled up, and how direct health interventions can partly overcome socioeconomic constraints.
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