Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet,Bangladesh

Objective

To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh.

Methods

In a cluster-randomized controlled trial, two strategies for neonatal care – known as home care and community care – were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy – compared with that of the pre-existing levels of maternal and neonatal care – was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis.

Findings

The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833–7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72–265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844–7628) and US$ 104.62 (95% CI: 65.15–266.60), respectively. The home-care package was cost-effective – with 95% certainty – if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective.

Conclusion

The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.     

The demand for health insurance coverage by low-income workers: can reduced premiums achieve full coverage?

OBJECTIVE: To assess the degree to which premium reductions will increase the participation in employer-sponsored health plans by low-income workers who are employed in small businesses. DATA SOURCES/STUDY SETTING: Sample of workers in small business (25 or fewer employees) in seven metropolitan areas. The data were gathered as part of the Small Business Benefits Survey, a telephone survey of small business conducted between October 1992 and February 1993. STUDY DESIGN: Probit regressions were used to estimate the demand for health insurance coverage by low-income workers. Predictions based on these findings were made to assess the extent to which premium reductions might increase coverage rates. DATA COLLECTION/EXTRACTION METHODS: Workers included in the sample were selected, at random, from a randomly generated set of firms drawn from Dun and Bradstreet's DMI (Dun's Market Inclusion). The response rate was 81 percent. FINDINGS: Participation in employer-sponsored plans is high when coverage is offered. However, even when coverage is offered to employees who have no other source of insurance, participation is not universal. Although premium reductions will increase participation in employer-sponsored plans, even large subsidies will not induce all workers to participate in employer-sponsored plans. For workers eligible to participate, subsidies as high as 75 percent of premiums are estimated to increase participation rates from 89.0 percent to 92.6 percent. For workers in firms that do not sponsor plans, similar subsidies are projected to achieve only modest increases in coverage above that which would be observed if the workers had access to plans at unsubsidized, group market rates. CONCLUSIONS: Policies that rely on voluntary purchase of coverage to reduce the number of uninsured will have only modest success.     

International public health research involving interpreters: a case study from Bangladesh

Background  

Cross-cultural and international research are important components of public health research, but the challenges of language barriers and working with interpreters are often overlooked, particularly in the case of qualitative research.     

The role of choice in health education intervention trials: a review and case study

Although the randomized, controlled trial (RCT) is considered the gold standard in research for determining the efficacy of health education interventions, such trials may be vulnerable to "preference effects"; that is, differential outcomes depending on whether an individual is randomized to his or her preferred treatment. In this study, we review theoretical and empirical literature regarding designs that account for such effects in medical research, and consider the appropriateness of these designs to health education research. To illustrate the application of a preference design to health education research, we present analyses using process data from a mixed RCT/preference trial comparing two formats (Group or Self-Directed) of the "Women take PRIDE" heart disease management program. Results indicate that being able to choose one's program format did not significantly affect the decision to participate in the study. However, women who chose the Group format were over 4 times as likely to attend at least one class and were twice as likely to attend a greater number of classes than those who were randomized to the Group format. Several predictors of format preference were also identified, with important implications for targeting disease-management education to this population.     

Rethinking literacy and women's health: a Bangladesh case study

Health and literacy are two major areas of women's development in the Third World. Although health and literacy have been recognized as essential elements for improving the quality of women's lives, questions emerge from Eurocentric and colonial assumptions about development, including the following: Does literacy have an impact on women's health? If it does, what are the mechanisms whereby literacy could have an impact on women's health? Using Bangladesh as a case study, I question the Eurocentric and colonial nature of dominant discourses in the answers to questions about literacy and women's health. I argue that literacy and women's health need to be reconsidered from the local women's standpoint since dominant discourses fail to take into consideration local women's worldviews, indigenous knowledge, and oral traditions. Finally, I make some recommendations for future research and programming in literacy and women's health in Bangladesh and in health care in Third World contexts.     

Factors affecting recruitment and retention of community health workers in a newborn care intervention in Bangladesh

Background

Well-trained and highly motivated community health workers (CHWs) are critical for delivery of many community-based newborn care interventions. High rates of CHW attrition undermine programme effectiveness and potential for implementation at scale. We investigated reasons for high rates of CHW attrition in Sylhet District in north-eastern Bangladesh.

Methods

Sixty-nine semi-structured questionnaires were administered to CHWs currently working with the project, as well as to those who had left. Process documentation was also carried out to identify project strengths and weaknesses, which included in-depth interviews, focus group discussions, review of project records (i.e. recruitment and resignation), and informal discussion with key project personnel.

Results

Motivation for becoming a CHW appeared to stem primarily from the desire for self-development, to improve community health, and for utilization of free time. The most common factors cited for continuing as a CHW were financial incentive, feeling needed by the community, and the value of the CHW position in securing future career advancement. Factors contributing to attrition included heavy workload, night visits, working outside of one's home area, familial opposition and dissatisfaction with pay.

Conclusions

The framework presented illustrates the decision making process women go through when deciding to become, or continue as, a CHW. Factors such as job satisfaction, community valuation of CHW work, and fulfilment of pre-hire expectations all need to be addressed systematically by programs to reduce rates of CHW attrition.     

Does health intervention improve socioeconomic inequalities of neonatal,infant and child mortality? Evidence from Matlab,Bangladesh

Background  

Although there are wide variations in mortality between developed and developing countries, socioeconomic inequalities in health exist in both the societies. The study examined socioeconomic inequalities of neonatal, infant and child mortality using data from the Matlab Health and Demographic Surveillance System of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).     

Using lay health workers: Case study of a community-based prenatal intervention

This article reports on the design and implementation of a prenatal outreach and education intervention for low income, Hispanic women living in three migrant and seasonal farmworker communities in Arizona. The program included three major elements: a Spanish language prenatal curriculum; a group of mature Hispanic women recruited from the target communities and trained as Comienzo Sano (healthy beginning) Promotoras (health promoters), and the organization of a support network of local health professionals. The rationale for the demonstration is reviewed, and the structure of the intervention is described. Factors which facilitated and constrained implementation of the program are identified, and guidelines are provided for other health care providers and health educators interested in developing similar programs.Joel S. Meister is Director, Southwest Border Rural Health Research Center, Member, Arizona Cancer Center: Louise H. Warrick is Research Assistant Professor of Family Medicine; Jill Guernsey de Zapién is Program Coordinator of Community Health; Anita H. Wood is Research Assistant in Rural Health; all in the Department of Family and Community Medicine, College of Medicine, University of Arizona, Tucson, Arizona 85724.The authors gratefully acknowledge the support and continued interest of the A.L. Mailman Family Foundation, which provided the initial funding for this project, of the March of Dimes, which has made possible the project's continuation by providing support for the promotoras, and of the Arizona Department of Health Services, Maternal and Child Health Division, for providing funding for the ongoing administration of the project. The Yuma County Health Department has provided the staff to supervise the program. We also wish to recognize the contribution made by the project's first coordinator and supervisor, W. Marie Roberts, RNP, CNP. During the latter phases of the project's first year, E. Lee Rosenthal, a graduate student intern from the School of Public Health, University of California at Berkeley, provided invaluable assistance, and, more recently, anthropological field work was conducted by Tamar Gottfried, a medical student at the University of Arizona.     

Community-based prevention marketing: organizing a community for health behavior intervention

This article describes the application and refinement of community-based prevention marketing (CBPM), an example of community-based participatory research that blends social marketing theories and techniques and community organization principles to guide voluntary health behavior change. The Florida Prevention Research Center has worked with a community coalition in Sarasota County, Florida to define locally important health problems and issues and to develop responsive health-promotion interventions. The CBPM framework has evolved as academic and community-based researchers have gained experience applying it. Community boards can use marketing principles to design evidence-based strategies for addressing local public health concerns. Based on 6 years of experience with the "Believe in All Your Possibilities" program, lessons learned that have led to revision and improvement of the CBPM framework are described.     

User fees for health care in developing countries: a case study of Bangladesh

In designing country health care programs to achieve the goals of the Alma Alta declaration of 'Health for All', developing countries have been confronted with the problem of increased health care needs and decreased available resources. Health economists have proferred several possible solutions to this fiscal shortfall, including cost-recovery measures through the imposition of user fees for curative services at government health facilities. Health care providers have been noticeably absent from discussions of the many possible implications of these fees; consequently, resultant programs and policies may be economically sound but may fail to place a sufficient emphasis on features designed to maintain and improve the health of the population. In the present paper we examine the possible impact of user fees on the health of individuals residing in Bangladesh, one potential candidate country for user fees. We note evidence that the existing government health care system appears already to be providing care to two of the most medically vulnerable groups in Bangladesh, the poor and women, and provide evidence that such fees may seriously interfere with maintaining this patient profile. We discuss the significant public health role that curative care provides for the individuals, their families and the wider community. We suggest that additional questions should be asked by health care providers, anthropologists and economists prior to institution of user fees in the government system and that such measures should first be introduced in an experimental format with a rigorous and comprehensive impact evaluation.     

Community-based health workers: building the identity of this hybrid,polyphonic character

This article analyzes the identity-building process for community-based health workers in the context of their role in the Health Family Program team and their interaction with the residents of communities where they work. Based on this analysis we specifically emphasize conflicts of interpretation, power relationships between both sides of identity-building for community-based health workers from three perspectives: that included in the official training of these workers, that produced by workers concerning themselves, and that transmitted by the community. The fact that community-based health workers live the reality of health practices in the neighborhoods where they live and work and are trained with biomedical references makes them actors that convey both the contradictions and the possibility for a deep dialogue between these two forms of knowledge and practice.     

新生儿重症监护病房医务人员手卫生依从性多中心干预研究

目的通过采取一系列干预措施提高我国新生儿重症监护病房(NICU)医务人员手卫生依从性。方法以多中心研究的方式,选取全国9个省及直辖市17所三级甲等医院,采用世界卫生组织(WHO)手卫生调查方法,每月对医务人员进行手卫生依从性调查。2013年10月1日—2014年3月31日为干预前;2014年4月1日—9月30日采取及时反馈与强化培训等干预措施,即为干预后。结果医务人员手卫生依从率干预前为80.29%,干预后为80.85%,干预前后比较,差异无统计学意义(P0.05)。不同规模NICU医务人员手卫生依从率干预前后比较,差异均有统计学意义(均P0.05),其中20张、20~30张床位的NICU医务人员手卫生依从率干预后均高于干预前(均P0.05),30张床位的NICU医务人员手卫生依从率干预后低于干预前(P0.001)。保洁人员手卫生依从率由干预前的58.82%提高至干预后的68.09%,差异有统计学意义(P0.05);不同手卫生指征中除清洁或无菌操作前,其他手卫生指征医务人员手卫生依从率干预前后比较,差异均有统计学意义(均P0.05)。结论我国NICU医务人员的手卫生依从性处于较高水平,采取强化培训、及时反馈等干预措施对不同规模NICU、不同岗位医务人员、不同手卫生指征的手卫生依从性有一定影响。     

Developing a web-based health promotion intervention: a case study from a brief motivational alcohol program

Public health researchers and practitioners reporting findings from intervention studies seldom report in depth the processes of intervention development. However, such information would be useful for several reasons: (a) it would help guide the development of new interventions and refinement or revision of existing ones, (b) it would provide a framework and methodology on which other health practitioners and researchers could build, and (c) it would increase transparency of the development process and enhance the interpretation of the intervention's effects. The purpose of this article is to begin addressing the "black box" of Web-based intervention development by presenting the method for developing a Web-based, brief, motivational alcohol intervention program that has shown evidence of efficacy for college students, called Michigan Prevention & Alcohol Safety for Students.     

Forces promoting health insurance coverage of homebirth: a case study in Washington State

The movement of childbirth to the hospital in the early 1900s and the eventual establishments of health insurance reimbursement for hospital birth--but not for homebirth--solidified and reflected physician dominance in the area of obstetrics. Until recently, it was rare that a health insurer or a health maintenance organization (HMO) would cover a homebirth. However, in Washington State the majority of health insurance groups cover homebirths, which are generally attended by licensed midwives. In this context, our research is a case study focused on answering the question: What are the forces promoting the extensive coverage of homebirth by health insurers in Washington State? Data were gathered primarily through fourteen (14) in-depth, audiotaped interviews with key informants in relevant agencies and organizations in the state (i.e., state offices; midwife and other professional associations; and health insurance groups). Results suggest that consumer demand was an important precipitating factor without which changes to health insurance coverage would likely not have been made. Additionally, changes in state policies and professional mobilization on the part of licensed midwives were critical factors facilitating the widespread reimbursement for homebirth. Health care organizations' concerns for cost containment had little impact on this health insurance trend. Our study concludes that jurisdictional openings in the system of professions can be facilitated by a small number of strategically positioned individuals.     

Assessing and improving data quality from community health workers: a successful intervention in Neno,Malawi

Setting:

A community health worker (CHW) program was established in Neno District, Malawi, in 2007 by Partners In Health in support of Ministry of Health activities. Routinely generated CHW data provide critical information for program monitoring and evaluation. Informal assessments of the CHW reports indicated poor quality, limiting the usefulness of the data.

Objectives:

1) To establish the quality of aggregated measures contained in CHW reports; 2) to develop interventions to address poor data quality; and 3) to evaluate changes in data quality following the intervention.

Design:

We developed a lot quality assurance sampling-based data quality assessment tool to identify sites with high or low reporting quality. Following the first assessment, we identified challenges and best practices and followed the interventions with two subsequent assessments.

Results:

At baseline, four of five areas were classified as low data quality. After 8 months, all five areas had achieved high data quality, and the reports generated from our electronic database became consistent and plausible.

Conclusion:

Program changes included improving the usability of the reporting forms, shifting aggregation responsibility to designated assistants and providing aggregation support tools. Local quality assessments and targeted interventions resulted in immediate improvements in data quality.     

Community health workers for universal health-care coverage: from fragmentation to synergy

To achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access. Since Alma-Ata, inconsistent support of community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs’ contribution.The current drive towards universal health coverage (UHC) presents an opportunity to enhance people’s access to health services and their trust, demand and use of such services through CHWs. For their potential to be fully realized, however, CHWs will need to be better integrated into national health-care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability. In moving towards UHC, much can be gained by investing in building CHWs’ skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to progress.