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Rudasingwa M, Yeboah E, Ridde V, Bonnet E, De Allegri M, Muula AS. How equitable is health spending on curative services and institutional delivery in Malawi? Evidence from a quasi-longitudinal benefit incidence analysis. Int J Equity Health 2022; 21:25. [PMID: 35180861 PMCID: PMC8856874 DOI: 10.1186/s12939-022-01624-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/24/2022] [Indexed: 11/18/2022] Open
Abstract
Background Malawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016. Methods We relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group. Results Socioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively. Conclusions Through its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection. Supplementary Information The online version contains supplementary material available at 10.1186/s12939-022-01624-5.
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Affiliation(s)
- Martin Rudasingwa
- Heidelberg Institute of Global Health, University Hospital & Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Edmund Yeboah
- Heidelberg Institute of Global Health, University Hospital & Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Valéry Ridde
- CEPED, Institute for Research on Sustainable Development, IRD-Université de Paris, ERL INSERM SAGESUD, Paris, France
| | - Emmanuel Bonnet
- IRD, UMR 215 Prodig, CNRS, Université Paris 1 Panthéon-Sorbonne, AgroParisTech, 5, Cours des Humanités, F-93 322, Aubervilliers, Cedex, France
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital & Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Adamson Sinjani Muula
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi. .,Kamuzu University of Health Sciences, Blantyre, Malawi.
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Ramsey K. Systems on the Edge: Developing Organizational Theory for the Persistence of Mistreatment in Childbirth. Health Policy Plan 2021; 37:400-415. [PMID: 34755181 DOI: 10.1093/heapol/czab135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 10/05/2021] [Accepted: 11/09/2021] [Indexed: 11/14/2022] Open
Abstract
Mistreatment in childbirth is institutionalized in many healthcare settings globally, causing widespread harm. Rising concern has elicited research on its prevalence and characteristics, with limited attention to developing explanatory theory. Mistreatment, a complex systemic and behavioral phenomenon, requires social science theory to explain its persistence despite official norms that promote respectful care. Diane Vaughan's normalization of organizational deviance theory from organizational sociology, emerged from studies of how things go wrong in organizations. Its multi-level framework provided an opportunity for analogical cross-case comparison to elaborate theory on mistreatment as normalized organizational deviance. To elaborate the theory, the Tanzanian public health system in the period of 2010-2015 was selected as a case. A broad Scopus search identified 4,068 articles published on the health system and maternal health in Tanzania of which 122 were selected. Data was extracted using a framework based on the theory and reviews of mistreatment in healthcare. Relationships and patterns emerged through comparative analysis across concepts and system levels and then were compared with Vaughan's theory and additional organizational theories. Analysis revealed that normalized scarcity at the macro-level combined with production pressures for biomedical care and imbalanced power-dependence altered values, structures, and processes in the health system. Meso-level actors struggled to achieve production goals with limited autonomy and resources, resulting in workarounds and informal rationing. Biomedical care was prioritized, and emotion work was rationed in provider interactions with women, which many women experienced as disrespect. Analogical comparison with another case of organizational deviance based on literature enabled a novel approach to elaborate theory. The emergent theory sheds light on opportunities to transform systems and routinize respectful care. Theory application in additional settings and exploration of other social theories is needed for further understanding of this complex problem.
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Affiliation(s)
- Kate Ramsey
- Columbia University Mailman School of Public Health, Department of Population and Family Health, 60 Haven Avenue, New York, NY 10032, USA
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Pitt C, Bath D, Binyaruka P, Borghi J, Martinez-Alvarez M. Falling aid for reproductive, maternal, newborn and child health in the lead-up to the COVID-19 pandemic. BMJ Glob Health 2021; 6:e006089. [PMID: 34108147 PMCID: PMC8190982 DOI: 10.1136/bmjgh-2021-006089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/21/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Catherine Pitt
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - David Bath
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Melisa Martinez-Alvarez
- Department of Global Health and Development, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Dakar, Senegal
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Gage A, Aryal A, Paul Joseph J, Cohen J. The price of quality care: cross-sectional associations between out-of-pocket payments and quality of care in six low-income countries. Trop Med Int Health 2021; 26:701-714. [PMID: 33638293 DOI: 10.1111/tmi.13567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess the relationship between out-of-pocket (OOP) payments and primary health care quality in six low-income countries: Afghanistan, the Democratic Republic of the Congo (DRC), Haiti, Nepal, Senegal and Tanzania. METHODS We examined the association between OOP payments and quality of care during antenatal care and sick child care visits using Service Provision Assessments data. We defined four process quality outcomes from observations of clinical care: visit duration, history-taking items asked, exam items performed, and counselling items delivered. The outcome is the total amount paid for services. We used multilevel models to test the relationship between OOP payments and each quality measure in public, private non-profit and private for-profit facilities controlling for patient, provider, and facility characteristics. RESULTS Across the six countries, an average of 42% of the 29 677 observed clients paid for their visit. In the adjusted models, OOP payments were positively associated with the visit duration during sick child visits, with history-taking and exam items during antenatal care visits, and with counselling in private for-profit facilities for both visit types. These associations were strong particularly in Afghanistan, the DRC and Haiti; for example, a high-quality antenatal care visit in the DRC would cost approximately USD 1.12 more than a visit with median quality. CONCLUSION Provider effort was associated with higher OOP payments for sick child and antenatal care services in the six countries studied. While many families are already spending high amounts on care, they must often spend even more to receive higher quality care.
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Affiliation(s)
- Anna Gage
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Amit Aryal
- Office of Member of Parliament, Gagan K Thapa, Kathmandu, Nepal
| | - Jean Paul Joseph
- Hôpital Universitaire de Mirebalais (HUM), Zanmi Lasante, Mirebalais, Haiti
| | - Jessica Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Chang AY, Cowling K, Micah AE, Chapin A, Chen CS, Ikilezi G, Sadat N, Tsakalos G, Wu J, Younker T, Zhao Y, Zlavog BS, Abbafati C, Ahmed AE, Alam K, Alipour V, Aljunid SM, Almalki MJ, Alvis-Guzman N, Ammar W, Andrei CL, Anjomshoa M, Antonio CAT, Arabloo J, Aremu O, Ausloos M, Avila-Burgos L, Awasthi A, Ayanore MA, Azari S, Azzopardi-Muscat N, Bagherzadeh M, Bärnighausen TW, Baune BT, Bayati M, Belay YB, Belay YA, Belete H, Berbada DA, Berman AE, Beuran M, Bijani A, Busse R, Cahuana-Hurtado L, Cámera LA, Catalá-López F, Chauhan BG, Constantin MM, Crowe CS, Cucu A, Dalal K, De Neve JW, Deiparine S, Demeke FM, Do HP, Dubey M, El Tantawi M, Eskandarieh S, Esmaeili R, Fakhar M, Fazaeli AA, Fischer F, Foigt NA, Fukumoto T, Fullman N, Galan A, Gamkrelidze A, Gezae KE, Ghajar A, Ghashghaee A, Goginashvili K, Haakenstad A, Haghparast Bidgoli H, Hamidi S, Harb HL, Hasanpoor E, Hassen HY, Hay SI, Hendrie D, Henok A, Heredia-Pi I, Herteliu C, Hoang CL, Hole MK, Homaie Rad E, Hossain N, Hosseinzadeh M, Hostiuc S, Ilesanmi OS, Irvani SSN, Jakovljevic M, Jalali A, James SL, Jonas JB, Jürisson M, Kadel R, Karami Matin B, Kasaeian A, Kasaye HK, Kassaw MW, Kazemi Karyani A, Khabiri R, Khan J, Khan MN, Khang YH, Kisa A, Kissimova-Skarbek K, Kohler S, Koyanagi A, Krohn KJ, Leung R, Lim LL, Lorkowski S, Majeed A, Malekzadeh R, Mansourian M, Mantovani LG, Massenburg BB, McKee M, Mehta V, Meretoja A, Meretoja TJ, Milevska Kostova N, Miller TR, Mirrakhimov EM, Mohajer B, Mohammad Darwesh A, Mohammed S, Mohebi F, Mokdad AH, Morrison SD, Mousavi SM, Muthupandian S, Nagarajan AJ, Nangia V, Negoi I, Nguyen CT, Nguyen HLT, Nguyen SH, Nosratnejad S, Oladimeji O, Olgiati S, Olusanya JO, Onwujekwe OE, Otstavnov SS, Pana A, Pereira DM, Piroozi B, Prada SI, Qorbani M, Rabiee M, Rabiee N, Rafiei A, Rahim F, Rahimi-Movaghar V, Ram U, Ranabhat CL, Ranta A, Rawaf DL, Rawaf S, Rezaei S, Roro EM, Rostami A, Rubino S, Salahshoor M, Samy AM, Sanabria J, Santos JV, Santric Milicevic MM, Sao Jose BP, Savic M, Schwendicke F, Sepanlou SG, Sepehrimanesh M, Sheikh A, Shrime MG, Sisay S, Soltani S, Soofi M, Soofi M, Srinivasan V, Tabarés-Seisdedos R, Torre A, Tovani-Palone MR, Tran BX, Tran KB, Undurraga EA, Valdez PR, van Boven JFM, Vargas V, Veisani Y, Violante FS, Vladimirov SK, Vlassov V, Vollmer S, Vu GT, Wolfe CDA, Yonemoto N, Younis MZ, Yousefifard M, Zaman SB, Zangeneh A, Zegeye EA, Ziapour A, Chew A, Murray CJL, Dieleman JL. Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995-2050. Lancet 2019; 393:2233-2260. [PMID: 31030984 PMCID: PMC6548764 DOI: 10.1016/s0140-6736(19)30841-4] [Citation(s) in RCA: 218] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/22/2019] [Accepted: 03/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Comprehensive and comparable estimates of health spending in each country are a key input for health policy and planning, and are necessary to support the achievement of national and international health goals. Previous studies have tracked past and projected future health spending until 2040 and shown that, with economic development, countries tend to spend more on health per capita, with a decreasing share of spending from development assistance and out-of-pocket sources. We aimed to characterise the past, present, and predicted future of global health spending, with an emphasis on equity in spending across countries. METHODS We estimated domestic health spending for 195 countries and territories from 1995 to 2016, split into three categories-government, out-of-pocket, and prepaid private health spending-and estimated development assistance for health (DAH) from 1990 to 2018. We estimated future scenarios of health spending using an ensemble of linear mixed-effects models with time series specifications to project domestic health spending from 2017 through 2050 and DAH from 2019 through 2050. Data were extracted from a broad set of sources tracking health spending and revenue, and were standardised and converted to inflation-adjusted 2018 US dollars. Incomplete or low-quality data were modelled and uncertainty was estimated, leading to a complete data series of total, government, prepaid private, and out-of-pocket health spending, and DAH. Estimates are reported in 2018 US dollars, 2018 purchasing-power parity-adjusted dollars, and as a percentage of gross domestic product. We used demographic decomposition methods to assess a set of factors associated with changes in government health spending between 1995 and 2016 and to examine evidence to support the theory of the health financing transition. We projected two alternative future scenarios based on higher government health spending to assess the potential ability of governments to generate more resources for health. FINDINGS Between 1995 and 2016, health spending grew at a rate of 4·00% (95% uncertainty interval 3·89-4·12) annually, although it grew slower in per capita terms (2·72% [2·61-2·84]) and increased by less than $1 per capita over this period in 22 of 195 countries. The highest annual growth rates in per capita health spending were observed in upper-middle-income countries (5·55% [5·18-5·95]), mainly due to growth in government health spending, and in lower-middle-income countries (3·71% [3·10-4·34]), mainly from DAH. Health spending globally reached $8·0 trillion (7·8-8·1) in 2016 (comprising 8·6% [8·4-8·7] of the global economy and $10·3 trillion [10·1-10·6] in purchasing-power parity-adjusted dollars), with a per capita spending of US$5252 (5184-5319) in high-income countries, $491 (461-524) in upper-middle-income countries, $81 (74-89) in lower-middle-income countries, and $40 (38-43) in low-income countries. In 2016, 0·4% (0·3-0·4) of health spending globally was in low-income countries, despite these countries comprising 10·0% of the global population. In 2018, the largest proportion of DAH targeted HIV/AIDS ($9·5 billion, 24·3% of total DAH), although spending on other infectious diseases (excluding tuberculosis and malaria) grew fastest from 2010 to 2018 (6·27% per year). The leading sources of DAH were the USA and private philanthropy (excluding corporate donations and the Bill & Melinda Gates Foundation). For the first time, we included estimates of China's contribution to DAH ($644·7 million in 2018). Globally, health spending is projected to increase to $15·0 trillion (14·0-16·0) by 2050 (reaching 9·4% [7·6-11·3] of the global economy and $21·3 trillion [19·8-23·1] in purchasing-power parity-adjusted dollars), but at a lower growth rate of 1·84% (1·68-2·02) annually, and with continuing disparities in spending between countries. In 2050, we estimate that 0·6% (0·6-0·7) of health spending will occur in currently low-income countries, despite these countries comprising an estimated 15·7% of the global population by 2050. The ratio between per capita health spending in high-income and low-income countries was 130·2 (122·9-136·9) in 2016 and is projected to remain at similar levels in 2050 (125·9 [113·7-138·1]). The decomposition analysis identified governments' increased prioritisation of the health sector and economic development as the strongest factors associated with increases in government health spending globally. Future government health spending scenarios suggest that, with greater prioritisation of the health sector and increased government spending, health spending per capita could more than double, with greater impacts in countries that currently have the lowest levels of government health spending. INTERPRETATION Financing for global health has increased steadily over the past two decades and is projected to continue increasing in the future, although at a slower pace of growth and with persistent disparities in per-capita health spending between countries. Out-of-pocket spending is projected to remain substantial outside of high-income countries. Many low-income countries are expected to remain dependent on development assistance, although with greater government spending, larger investments in health are feasible. In the absence of sustained new investments in health, increasing efficiency in health spending is essential to meet global health targets. FUNDING Bill & Melinda Gates Foundation.
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Huicho L, Huayanay-Espinoza CA, Hernandez P, Niño de Guzman J, Rivera-Ch M. Enabling reproductive, maternal, neonatal and child health interventions: Time trends and driving factors of health expenditure in the successful story of Peru. PLoS One 2018; 13:e0206455. [PMID: 30379907 PMCID: PMC6209344 DOI: 10.1371/journal.pone.0206455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 10/13/2018] [Indexed: 11/19/2022] Open
Abstract
We compared expenditure trends for reproductive, maternal, neonatal and child health (RMNCH) with trends in RMNCH service coverage in Peru. We used National Health Accounts data to report on total health expenditure by source; the Countdown database for trends in external funding to RMNCH, and Ministry of Finance data for trends in domestic funding to RMNCH. We undertook over 170 interviews and group discussions to explore factors explaining expenditure trends. We describe trends in total health expenditure and RMNCH expenditure in constant 2012 US$ between 1995 and 2012. We estimated expenditure to coverage ratios. There was a substantial increase in domestic health expenditure over the period. However, domestic health expenditure as share of total government spending and GDP remained stable. Out-of-pocket health spending (OOPS) as a share of total health expenditure remained above 35%, and increased in real terms. Expenditure on reproductive health per woman of reproductive age varied from US$ 1.0 in 2002 to US$ 6.3 in 2012. Expenditure on maternal and neonatal health per pregnant woman increased from US$ 34 in 2000 to US$ 512 in 2012, and per capita expenditure on under-five children increased from US$ 5.6 in 2000 to US$ 148.6 in 2012. Increased expenditure on RMNCH reflects a greater political support for RMNCH, along with greater emphasis on social assistance, family planning, and health reforms targeting poor areas, and a recent emphasis on antipoverty and crosscutting equitable policies and programmes focused on nutrition and maternal and neonatal mortality. Increasing domestic RMNCH expenditure likely enabled Peru to achieve substantial health gains. Peru can provide useful lessons to other countries struggling to achieve sustained gains in RMNCH by relying on their own health financing.
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Affiliation(s)
- Luis Huicho
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
- Centro de Investigación en Salud Materna e Infantil, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia and Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Carlos A. Huayanay-Espinoza
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
- Centro de Investigación en Salud Materna e Infantil, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Patricia Hernandez
- Netherlands Interdisciplinary Demographic Institute, Rotterdam, The Netherlands
| | | | - Maria Rivera-Ch
- Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
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Berman P, Mann C, Ricculli ML. Can Ethiopia Finance the Continued Development of Its Primary Health Care System If External Resources Decline? Health Syst Reform 2018; 4:227-238. [DOI: 10.1080/23288604.2018.1448240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- Peter Berman
- Global Health and Population Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Carlyn Mann
- Global Health and Population Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Marie-Louise Ricculli
- Global Health and Population Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Ruducha J, Mann C, Singh NS, Gemebo TD, Tessema NS, Baschieri A, Friberg I, Zerfu TA, Yassin M, Franca GA, Berman P. How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case study. LANCET GLOBAL HEALTH 2018; 5:e1142-e1151. [PMID: 29025635 PMCID: PMC5640803 DOI: 10.1016/s2214-109x(17)30331-5] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/26/2017] [Accepted: 08/08/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND 3 years before the 2015 deadline, Ethiopia achieved Millennium Development Goal 4. The under-5 mortality decreased 69%, from 205 deaths per 1000 livebirths in 1990 to 64 deaths per 1000 livebirths in 2013. To understand the underlying factors that contributed to the success in achieving MDG4, Ethiopia was selected as a Countdown to 2015 case study. METHODS We used a set of complementary methods to analyse progress in child health in Ethiopia between 1990 and 2014. We used Demographic Health Surveys to analyse trends in coverage and equity of key reproductive, maternal health, and child health indicators. Standardised tools developed by the Countdown Health Systems and Policies working group were used to understand the timing and content of health and non-health policies. We assessed longitudinal trends in health-system investment through a financial analysis of National Health Accounts, and we used the Lives Saved Tool (LiST) to assess the contribution of interventions towards reducing under-5 mortality. FINDINGS The annual rate of reduction in under-5 mortality increased from 3·3% in 1990-2005 to 7·8% in 2005-13. The prevalence of stunting decreased from 60% in 2000 to 40% in 2014. Overall levels of coverage of reproductive, maternal health, and child health indicators remained low, with disparities between the lowest and highest wealth quintiles despite improvement in coverage for essential health interventions. Coverage of child immunisation increased the most (21% of children in 2000 vs 80% of children in 2014), followed by coverage of satisfied demand for family planning by women of reproductive age (19% vs 63%). Provision of antenatal care increased from 10% of women in 2000 to 32% of women in 2014, but only 15% of women delivered with a skilled birth attendant by 2014. A large upturn occurred after 2005, bolstered by a rapid increase in health funding that facilitated the accelerated expansion of health infrastructure and workforce through an innovative community-based delivery system. The LiST model could explain almost 50% of the observed reduction in child mortality between 2000 and 2011; and changes in nutritional status were responsible for about 50% of the 469 000 lives saved between 2000 and 2011. These developments occurred within a multisectoral policy platform, integrating child survival and stunting goals within macro-level policies and programmes for reducing poverty and improving agricultural productivity, food security, water supply, and sanitation. INTERPRETATION The reduction of under-5 mortality in Ethiopia was the result of combined activities in health, nutrition, and non-health sectors. However, Ethiopia still has high neonatal and maternal morbidity and mortality from preventable causes and an unfinished agenda in reducing inequalities, improving coverage of effective interventions, and strengthening multisectoral partnerships for further progress. FUNDING Bill & Melinda Gates Foundation and Government of Canada.
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Affiliation(s)
| | - Carlyn Mann
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Neha S Singh
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Tsegaye D Gemebo
- School of Public Health, Woliata Sodo University, Woliata Sodo, SNNPR, Ethiopia
| | | | - Angela Baschieri
- Maternal, Adolescent, Reproductive and Child Health Centre, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Taddese A Zerfu
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia; Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Mohammed Yassin
- Amhara Regional Health Bureau, South Wollo and Dessie City, Ethiopia
| | | | - Peter Berman
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
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Bartlett L, LeFevre A, Zimmerman L, Saeedzai SA, Turkmani S, Zabih W, Tappis H, Becker S, Winch P, Koblinsky M, Rahmanzai AJ. Progress and inequities in maternal mortality in Afghanistan (RAMOS-II): a retrospective observational study. LANCET GLOBAL HEALTH 2017; 5:e545-e555. [PMID: 28395847 DOI: 10.1016/s2214-109x(17)30139-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/21/2017] [Accepted: 03/15/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The risk of maternal death in Afghanistan is among the highest in the world; however, the risks within the country are poorly understood. Subnational maternal mortality estimates are needed along with a broader understanding of determinants to guide future maternal health programmes. Here we aimed to study maternal mortality risk and causes, care-seeking patterns, and costs within the country. METHODS We did a household survey (RAMOS-II) in the urban area of Kabul city and the rural area of Ragh, Badakshan. Questionnaires were administered to senior female household members and data were collected by a team of female interviewers with secondary school education. Information was collected about all deaths, livebirths, stillbirths, health-care access and costs, household income, and assets. Births were documented using a pregnancy history. We investigated all deaths in women of reproductive age (12-49 years) since January, 2008, using verbal autopsy. Community members; service providers; and district, provincial, and national officials in each district were interviewed to elicit perceptions of changes in maternal mortality risk and health service provision, along with programme and policy documentation of maternal care coverage. FINDINGS Data were collected between March 2, 2011, and Oct 16, 2011, from 130 688 participants: 63 329 in Kabul and 67 359 in Ragh. The maternal mortality ratio in Ragh was quadruple that in Kabul (713 per 100 000 livebirths, 95% CI 553-873 in Ragh vs 166, 63-270 in Kabul). We recorded similar patterns for all other maternal death indicators, including the maternal mortality rate (1·7 per 1000 women of reproductive age, 95% CI 1·3-2·1 in Ragh vs 0·2, 0·1-0·3 in Kabul). Infant mortality also differed significantly between the two areas (115·5 per 1000 livebirths, 95% CI 108·6-122·3 in Ragh vs 24·8, 20·5-29·0 in Kabul). In Kabul, 5594 (82%) of 6789 women reported a skilled attendant during recent deliveries compared with 381 (3%) of 11 366 women in Ragh. An estimated 85% of women in Kabul and 47% in Ragh incurred delivery costs (mean US$66·20, IQR $61·30 in Kabul and $9·89, $11·87 in Ragh). Maternal complications were the third leading cause of death in women of reproductive age in Kabul, and the leading cause in Ragh, and were mainly due to hypertensive diseases of pregnancy. The maternal mortality rate decreased significantly between 2002 and 2011 in both Kabul (by 71%) and Ragh (by 84%), plus all other maternal mortality indicators in Ragh. INTERPRETATION Remarkable maternal and other mortality reductions have occurred in Afghanistan, but the disparity between urban and rural sites is alarming, with all maternal mortality indicators significantly higher in Ragh than in Kabul. Customised service delivery is needed to ensure parity for different geographic and security settings. FUNDING United States Agency for International Development (USAID).
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Affiliation(s)
- Linda Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Amnesty LeFevre
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linnea Zimmerman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sayed Ataullah Saeedzai
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Ministry of Public Health, Kabul, Afghanistan
| | - Sabera Turkmani
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Weeda Zabih
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Center For Research and Learning, Toronto, ON, Canada
| | - Hannah Tappis
- Technical Leadership Office, Jhpiego, Baltimore, MD, USA
| | - Stan Becker
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Peter Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marge Koblinsky
- US Agency for International Development, Washington, DC, USA
| | - Ahmed Javed Rahmanzai
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Emerging Leaders Consulting Services, Kabul, Afghanistan
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Malik MA, Nahyoun AS, Rizvi A, Bhatti ZA, Bhutta ZA. Expenditure tracking and review of reproductive maternal, newborn and child health policy in Pakistan. Health Policy Plan 2017; 32:781-790. [PMID: 28334970 DOI: 10.1093/heapol/czx021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2017] [Indexed: 11/12/2022] Open
Abstract
Since 2001 substantial resources have been allocated to the reproductive, maternal, newborn and child health sector (RMNCH) in Pakistan. Many new programmes have been started and coverage of some existing programmes has been extended to un-served and rural areas. Despite these efforts the Millennium Development Goals (MDGs) 4 and 5 were not achieved (2000-15). Maternal Mortality Ratio was reduced to 170 per 100 000 live births (target 100) by 2013 at an annual reduction rate of 3.6% (1990-2013). Against the target of 46 per 1000 live births, the Under Five Mortality Rate was reduced to 81 per 1000 live births by 2015 at an annual reduction rate of 2.1% (1990-2015). We evaluated the comparative expenditures for the RMNCH sector and analysed impact of public expenditures on the use of the public facilities for the RMNCH services. Expenditure on RMNCH increased by 181% (2000-10), reaching PKR 628.79 billion (US$9.67 billion). The Share of the RMNCH expenditure in the total health expenditure increased from 16 to 21% (2005-10). The share of official development assistance for the RMNCH increased from 36 to 51% (2003-10). Equity was modestly achieved with a greater proportion of the poor using public facilities for the childhood diarrhoea (Concentration Index -0.06 in 2001-02 to - 0.11 in 2010-11) and reduction in the proportion of the rich using the public health facilities for institutional births (Concentration Index 0.30 in 2001-02 to 0.25 in 2010-11). Overall the RMNCH disease control programmes focused on vertical primary health approach and targeted the district health system in the un-served areas. Our findings confirm that diseconomies of scale, donor dependence and supply side perspective could only result in a modest progress towards achieving the MDGs. We call for urgent attention of the policy makers for the integration of the vertical and the routine primary health care and reliance on indigenous sustainable healthcare financing. We also recommend acknowledging economic perspective on health policy and health programmes.
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Affiliation(s)
- Muhammad Ashar Malik
- Department of Community Health Sciences, Aga Khan University, Stadium road, Karachi, Pakistan
| | | | - Arjumand Rizvi
- Department of Paediatrics and Child Health, Division of Women and Child Health, Aga Khan University, Stadium road, Karachi, Pakistan
| | - Zaid Ahmad Bhatti
- Department of Paediatrics and Child Health, Division of Women and Child Health, Aga Khan University, Stadium road, Karachi, Pakistan
| | - Zulfiqar Ahmad Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Stadium road, Karachi, Pakistan and Centre for Global Child Health, Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada
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11
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Manyazewal T. Using the World Health Organization health system building blocks through survey of healthcare professionals to determine the performance of public healthcare facilities. ACTA ACUST UNITED AC 2017; 75:50. [PMID: 29075485 PMCID: PMC5651704 DOI: 10.1186/s13690-017-0221-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/12/2017] [Indexed: 01/01/2023]
Abstract
Background Acknowledging the health system strengthening agenda, the World Health Organization (WHO) has formulated a health systems framework that describes health systems in terms of six building blocks. This study aimed to determine the current status of the six WHO health system building blocks in public healthcare facilities in Ethiopia. Methods A quantitative, cross-sectional study was conducted in five public hospitals in central Ethiopia which were in a post-reform period. A self-administered, structured questionnaire which covered the WHO’s six health system building blocks was used to collect data on healthcare professionals who consented. Data was analyzed using IBM SPSS version 20. Results The overall performance of the public hospitals was 60% when weighed against the WHO building blocks which, in this procedure, needed a minimum of 80% score. For each building block, performance scores were: information 53%, health workforce 55%, medical products and technologies 58%, leadership and governance 61%, healthcare financing 62%, and service delivery 69%. There existed a significant difference in performance among the hospitals (p < .001). Conclusion The study proved that the WHO’s health system building blocks are useful for assessing the process of strengthening health systems in Ethiopia. The six blocks allow identifying different improvement opportunities in each one of the hospitals. There was no contradiction between the indicators of the WHO building blocks and the health sustainable development goal (SDG) objectives. However, such SDG objectives should not be a substitute for strategies to strengthen health systems.
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Affiliation(s)
- Tsegahun Manyazewal
- Department of Health Studies, College of Human Science, University of South Africa, Pretoria, P.O. BOX 392 South Africa
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Berman P, Requejo J, Bhutta ZA, Singh NS, Owen H, Lawn JE. Countries’ progress for women’s and children’s health in the Millennium Development Goal era: the Countdown to 2015 experience. BMC Public Health 2016. [PMCID: PMC5025817 DOI: 10.1186/s12889-016-3398-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Moucheraud C, Owen H, Singh NS, Ng CK, Requejo J, Lawn JE, Berman P. Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5? BMC Public Health 2016; 16 Suppl 2:794. [PMID: 27633919 PMCID: PMC5025828 DOI: 10.1186/s12889-016-3401-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress. Methods Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing). Results The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30–40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers. Conclusions These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3401-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Corrina Moucheraud
- University of California Fielding School of Public Health, Los Angeles, CA, 90095, USA.
| | - Helen Owen
- Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Neha S Singh
- Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | | | - Jennifer Requejo
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Joy E Lawn
- Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Peter Berman
- Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
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