A Systematic Review of Economic Evaluation Methodologies Between Resource-Limited and Resource-Rich Countries: A Case of Rotavirus Vaccines

Background

For more than three decades, the number and influence of economic evaluations of healthcare interventions have been increasing and gaining attention from a policy level. However, concerns about the credibility of these studies exist, particularly in studies from low- and middle- income countries (LMICs). This analysis was performed to explore economic evaluations conducted in LMICs in terms of methodological variations, quality of reporting and evidence used for the analyses. These results were compared with those studies conducted in high-income countries (HICs).

Methods

Rotavirus vaccine was selected as a case study, as it is one of the interventions that many studies in both settings have explored. The search to identify individual studies on rotavirus vaccines was performed in March 2014 using MEDLINE and the National Health Service Economic Evaluation Database. Only full economic evaluations, comparing cost and outcomes of at least two alternatives, were included for review. Selected criteria were applied to assess methodological variation, quality of reporting and quality of evidence used.

Results

Eighty-five studies were included, consisting of 45 studies in HICs and 40 studies in LMICs. Seventy-five percent of the studies in LMICs were published by researchers from HICs. Compared with studies in HICs, the LMIC studies showed less methodological variety. In terms of the quality of reporting, LMICs had a high adherence to technical criteria, but HICs ultimately proved to be better. The same trend applied for the quality of evidence used.

Conclusion

Although the quality of economic evaluations in LMICs was not as high as those from HICs, it is of an acceptable level given several limitations that exist in these settings. However, the results of this study may not reflect the fact that LMICs have developed a better research capacity in the domain of health economics, given that most of the studies were in theory led by researchers from HICs. Putting more effort into fostering the development of both research infrastructure and capacity building as well as encouraging local engagement in LMICs is thus necessary.

     

Pathogenic landscapes: Interactions between land, people, disease vectors, and their animal hosts

Background

Extensive public health gains have benefited high-income countries in recent decades, however, citizens of low and middle-income countries (LMIC) have largely not enjoyed the same advancements. This is in part due to the fact that public health data - the foundation for public health advances - are rarely collected in many LMIC. Injury data are particularly scarce in many low-resource settings, despite the huge associated burden of morbidity and mortality. Advances in freely-accessible and easy-to-use information and communication (ICT) technology may provide the impetus for increased public health data collection in settings with limited financial and personnel resources.

Methods and Results

A pilot study was conducted at a hospital in Cape Town, South Africa to assess the utility and feasibility of using free (non-licensed), and easy-to-use Social Web and GeoWeb tools for injury surveillance in low-resource settings. Data entry, geocoding, data exploration, and data visualization were successfully conducted using these technologies, including Google Spreadsheet, Mapalist, BatchGeocode, and Google Earth.

Conclusion

This study examined the potential for Social Web and GeoWeb technologies to contribute to public health data collection and analysis in low-resource settings through an injury surveillance pilot study conducted in Cape Town, South Africa. The success of this study illustrates the great potential for these technologies to be leveraged for public health surveillance in resource-constrained environments, given their ease-of-use and low-cost, and the sharing and collaboration capabilities they afford. The possibilities and potential limitations of these technologies are discussed in relation to the study, and to the field of public health in general.     

The cost-effectiveness of preventing mother-to-child transmission of HIV in low- and middle-income countries: systematic review

Background

Although highly effective prevention interventions exist, the epidemic of paediatric HIV continues to challenge control efforts in resource-limited settings. We reviewed the cost-effectiveness of interventions to prevent mother-to-child transmission (MTCT) of HIV in low- and middle-income countries (LMICs). This article presents syntheses of evidence on the costs, effects and cost-effectiveness of HIV MTCT strategies for LMICs from the published literature and evaluates their implications for policy and future research.

Methods

Candidate studies were identified through a comprehensive database search including PubMed, Embase, Cochrane Library, and EconLit restricted by language (English or French), date (January 1st, 1994 to January 17^th, 2011) and article type (original research). Articles reporting full economic evaluations of interventions to prevent or reduce HIV MTCT were eligible for inclusion. We searched article bibliographies to identify additional studies. Two authors independently assessed eligibility and extracted data from studies retained for review. Study quality was appraised using a modified BMJ checklist for economic evaluations. Data were synthesised in narrative form.

Results

We identified 19 articles published in 9 journals from 1996 to 2010, 16 concerning sub-Saharan Africa. Collectively, the articles suggest that interventions to prevent paediatric infections are cost-effective in a variety of LMIC settings as measured against accepted international benchmarks. In concentrated epidemics where HIV prevalence in the general population is very low, MTCT strategies based on universal testing of pregnant women may not compare well against cost-effectiveness benchmarks, or may satisfy formal criteria for cost-effectiveness but offer a low relative value as compared to competing interventions to improve population health.

Conclusions and Recommendations

Interventions to prevent HIV MTCT are compelling on economic grounds in many resource-limited settings and should remain at the forefront of global HIV prevention efforts. Future cost-effectiveness analyses can help to ensure that pMTCT interventions for LMICs reach their full potential by focussing on unanswered questions in four areas: local assessment of rapidly evolving HIV MTCT options; strategies to improve coverage and reach underserved populations; evaluation of a more comprehensive set of MTCT approaches including primary HIV prevention and reproductive counselling; integration of HIV MTCT and other sexual and reproductive health services.     

Adoption and compliance in second-hand smoking bans: a global econometric analysis

Objectives

We examine the determinants governing both countries’ enactment of smoking bans in public places and their ability to successfully put these bans into effect.

Methods

Using a large sample (N = 99–184) of low-, middle- and high-income countries, econometric techniques are used to estimate the influence of several variables on cross-national variations in the adoption and compliance of second-hand smoke laws (2010).

Results

We find similarities in the determinants of adoption and compliance. Yet more notable are the differences, with several political economy factors which have a statistically significant influence on countries’ level of compliance with existing smoke-free laws in public places found not to consistently influence their propensity to adopt bans in the first place. Possible explanations for this discrepancy are that governments are motivated to adopt smoking bans for reasons other than protecting the health of their citizens and that the real costs of smoking bans are predominantly borne at the compliance stage.

Conclusions

More effort needs to be made to ensure that governments realize their existing policy commitments through effective enforcement of bans.     

Innovations in health care and mortality trends from five cancers in seven European countries between 1970 and 2005

Objectives

Although the contribution of health care to survival from cancer has been studied extensively, much less is known about its contribution to population health. We examine how medical innovations have influenced trends in cause-specific mortality at the national level.

Methods

Based on literature reviews, we selected six innovations with proven effectiveness against cervical cancer, Hodgkin’s disease, breast cancer, testicular cancer, and leukaemia. With data on the timing of innovations and cause-specific mortality (1970–2005) from seven European countries we identified associations between innovations and favourable changes in mortality.

Results

For none of the five specific cancers, sufficient evidence for an association between introduction of innovations and a positive change in mortality could be found. The highest association was found between the introduction of Tamoxifen and breast cancer mortality.

Conclusions

The lack of evidence of health care effectiveness may be due to gradual improvements in treatment, to effects limited to certain age groups or cancer subtypes, and to contemporaneous changes in cancer incidence. Research on the impact of health care innovations on population health is limited by unreliable data on their introduction.     

Assessing Ghana’s eHealth workforce: implications for planning and training

Background

eHealth—the proficient application of information and communication technology to support healthcare delivery—has been touted as one of the best solutions to address quality and accessibility challenges in healthcare. Although eHealth could be of more value to health systems in low- and middle-income countries (LMICs) where resources are limited, identification of a competent workforce which can develop and maintain eHealth systems is a key barrier to adoption. Very little is known about the actual or optimal states of the eHealth workforce needs of LMICs. The objective of this study was to develop a framework to characterize and assess the eHealth workforce of hospitals in LMICs.

Methods

To characterize and assess the sufficiency of the workforce, we designed this study in twofold. First, we developed a general framework to categorize the eHealth workforce at any LMIC setting. Second, we combined qualitative data, using semi-structured interviews and the Workload Indicator of Staffing Needs (WISN) to assess the sufficiency of the eHealth workforce in selected hospitals in a LMIC setting like Ghana.

Results

We surveyed 76 (60%) of the eHealth staff from three hospitals in Ghana—La General Hospital, University of Ghana Hospital, and Greater Accra Regional Hospital. We identified two main eHealth cadres, technical support/information technology (IT) and health information management (HIM). While the HIM cadre presented diversity in expertise, the IT group was dominated by training in Science (42%) and Engineering (55%), and the majority (87%) had at least a bachelor’s degree. Health information clerk (32%), health information officer (25%), help desk specialist (20%), and network administrator (11%) were the most dominant roles. Based on the WISN assessment, the eHealth workforce at all the surveyed sites was insufficient. La General and University of Ghana were operating at 10% of required IT staff capacity, while Ridge was short by 42%.

Conclusions

We have developed a framework to characterize and assess the eHealth workforce in LMICs. Applying it to a case study in Ghana has given us a better understanding of potential eHealth staffing needs in LMICs, while providing the quantitative basis for building the requisite human capital to drive eHealth initiatives. Educators can also use our results to explore competency gaps and refine curricula for burgeoning training programs. The findings of this study can serve as a springboard for other LMICs to assess the effects of a well-trained eHealth workforce on the return on eHealth investments.

     

Validation of a measurement instrument for parental child feeding in a low and middle-income country

Background

Parental child feeding practices (PCFP) are a key factor influencing children’s dietary intake, especially in the preschool years when eating behavior is being established. Instruments to measure PCFP have been developed and validated in high-income countries with a high prevalence of childhood obesity. The aim of this study was to test the appropriateness, content, and construct validity of selected measures of PCFP in a low and middle-income country (LMIC) in which there is both undernutrition and obesity in children.

Methods

An expert panel selected subscales and items from measures of PCFP that have been well-tested in high-income countries to measure both “coercive” and “structural” behaviors. Two sequential cross-sectional studies (Study 1, n =?154; Study 2, n =?238) were conducted in two provinces in Indonesia. Findings of the first study were used to refine subscales used in Study 2. An additional qualitative study tested content validity from the perspective of mothers (the intended respondents). Factorial validation and reliability were also tested. Convergent validity was tested with child nutritional status.

Results

In Study 1, a confirmatory factor analysis (CFA) model with 11 factors provided good fit (RMSEA?=?0.045; CFI?=?0.95 and TLI?=?0.95) after two subscales were removed. Reliability was good among seven of the subscales. Following a decision to take out an additional subscale, the instrument was tested for factorial validity (Study 2). A CFA model with 10 subscales provided good fit (RMSEA?=?0.03; CFI?=?0.92 and TLI?=?0.90). The reliability of subscales was lower than in Study 1. Convergent validity with nutrition status was found with two subscales.

Conclusions

The two studies provide evidence of acceptable psychometric properties for 10 subscales from tested instruments to measure PCFP in Indonesia. This provides the first evidence of the validity of these measures in a LMIC setting. Some shortcomings, such in the reliability of some subscales and further tests of predictive validity, require further investigation.

     

Capturing lessons learned from evidence-to-policy initiatives through structured reflection

Background

Knowledge translation platforms (KTPs), which are partnerships between policymakers, stakeholders, and researchers, are being established in low- and middle-income countries (LMICs) to enhance evidence-informed health policymaking (EIHP). This study aims to gain a better understanding of the i) activities conducted by KTPs, ii) the way in which KTP leaders, policymakers, and stakeholders perceive these activities and their outputs, iii) facilitators that support KTP work and challenges, and the lessons learned for overcoming such challenges, and iv) factors that can help to ensure the sustainability of KTPs.

Methods

This paper triangulated qualitative data from: i) 17 semi-structured interviews with 47 key informants including KTP leaders, policymakers, and stakeholders from 10 KTPs; ii) document reviews, and iii) observation of deliberations at the International Forum on EIHP in LMICs held in Addis Ababa in August 2012. Purposive sampling was used and data were analyzed using thematic analysis.

Results

Deliberative dialogues informed by evidence briefs were identified as the most commendable tools by interviewees for enhancing EIHP. KTPs reported that they have contributed to increased awareness of the importance of EIHP and strengthened relationships among policymakers, stakeholders, and researchers. Support from policymakers and international funders facilitated KTP activities, while the lack of skilled human resources to conduct EIHP activities impeded KTPs. Ensuring the sustainability of EIHP initiatives after the end of funding was a major challenge for KTPs. KTPs reported that institutionalization within the government has helped to retain human resources and secure funding, whereas KTPs hosted by universities highlighted the advantage of autonomy from political interests.

Conclusions

The establishment of KTPs is a promising development in supporting EIHP. Real-time lesson drawing from the experiences of KTPs can support improvements in the functioning of KTPs in the short term, while making the case for sustaining their work in the long term. Lessons learned can help to promote similar EIHP initiatives in other countries.     

Global burden of stroke in 2010: a pooling analysis of worldwide population-based data on stroke incidence

Aim

Stroke remains one of the most devastating conditions of all neurological diseases. Reliable information about its prevalence worldwide is essential to the development of national policies for the prevention and control of this condition.

Subjects and methods

We conducted a systematic review of the literature on the incidence of first-ever stroke and searched for population-based studies published between 1990 and 2013. Stroke incidence was analyzed by country income: high-income countries (HICs) and low- to middle-income countries (LMICs). We used epidemiological modeling to define age- and sex-specific incidence rates in the two country income groups together with 2010 United Nations population sizes to estimate the global incidence of stroke.

Results

Forty-two studies met the inclusion criteria (26,672,101 participants; 74,840 patients). In HICs, the incidence at age 45–49 years was 44.98 (40.75–49.65) for males and 46.52 (42.39–51.05) for females, and at age 85–89 years, it was 2,215.02 (1,919.53–2,554.82) for males and 1,620.37 (1,416.65–1,852.83) for females. The stroke incidence for both males and females was higher in LMICs than in HICs at age 45–49 years (69.63 [57.99–83.60] and 58.84 [49.63–69.76], respectively). Furthermore, it was higher in LMICs than HICs at age 85–89 years (2,777.58 [2,035.20–3,780.31] and 2,311.43 [1,752.27–3,043.48], respectively). Globally, more than 6 million people experienced first-stroke events in 2010, with 70.57 % of sufferers living in LMICs.

Conclusion

Stroke is a significant public health burden worldwide. The prevention, detection, treatment, and control of this condition should be a top priority.

     

Perspectives of physicians practicing in low and middle income countries towards generic medicines: A narrative review

Objectives

This review was conducted to document published literature related to physicians’ knowledge, attitudes, and perceptions of generic medicines in low- and middle-income countries (LMICs) and to compare the findings with high-income countries.

Methods

A systematic search of articles published in peer-reviewed journals from January 2001 to February 2013 was performed. The search comprised nine electronic databases. The search strategy involved using Boolean operators for combinations of the following terms: generic medicines, generic medications, generic drugs, generic, generic substitution, generic prescribing, international non-proprietary, prescribers, doctors, general practitioners, physicians, and specialists.

Results

Sixteen articles were included in this review. The majority (n = 11) were from high income countries and five from LMICs. The main difference between high income countries and LMICs is that physicians from high income countries generally have positive views whereas those from LMICs tend to have mixed views regarding generic medicines. Few similarities were identified among different country income groups namely low level of physicians’ knowledge of the basis of bioequivalence testing, cost of generic medicines as an encouraging factor for generic medicine prescribing, physicians’ concerns towards safety and quality of generic medicines and effect of pharmaceutical sales representative on generic medicine prescribing.

Conclusion

The present literature review revealed that physicians from LMICs tend to have mixed views regarding generic medicines. This may be due to differences in the health care system and pharmaceutical funding system, medicine policies, the level of educational interventions, and drug information sources in countries of different income levels.     

Strange bedfellows: bridging the worlds of academia,public health and the sex industry to improve sexual health outcomes

Background

There is increasing interest in building the capacity of researchers in low and middle income countries (LMIC) to address their national priority health and health policy problems. However, the number and variety of partnerships and funding arrangements can create management problems for LMIC research institutes. This paper aims to identify problems faced by a health research institute in Bangladesh, describe two strategies developed to address these problems, and identify the results after three years of implementation.

Methods

This paper uses a mixture of quantitative and qualitative data collected during independent annual reviews of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) between 2006 and 2010. Quantitative data includes the number of research activities according to strategic priority areas, revenues collected and expenditure. Qualitative data includes interviews of researchers and management of ICDDR,B, and of research users and key donors. Data in a Monitoring and Evaluation Framework (MEF) were assessed against agreed indicators.

Results

The key problems faced by ICDDR,B in 2006 were insufficient core funds to build research capacity and supporting infrastructure, and an inability to direct research funds towards the identified research priorities in its strategic plan. Two strategies were developed to address these problems: a group of donors agreed to provide unearmarked pooled core funding, and accept a single common report based on an agreed MEF. On review after three years, there had been significant increases in total revenue, and the ability to allocate greater amounts of money on capacity building and infrastructure. The MEF demonstrated progress against strategic objectives, and better alignment of research against strategic priorities. There had also been changes in the sense of ownership and collaboration between ICDDR,B's management and its core donors.

Conclusions

The changes made to funding relationships supported and monitored by an effective MEF enabled the organisation to better align funding with research priorities and to invest in capacity building. This paper identified key issues for capacity building for health research in low and middle income countries. The findings have relevance to other research institutes in similar contexts to advocate and support research capacity strengthening efforts.     

Linking Research to Global Health Equity: The Contribution of Product Development Partnerships to Access to Medicines and Research Capacity Building

Certain product development partnerships (PDPs) recognize that to promote the reduction of global health disparities they must create access to their products and strengthen research capacity in developing countries.We evaluated the contribution of 3 PDPs—Medicines for Malaria Venture, Drugs for Neglected Diseases Initiative, and Institute for One World Health—according to Frost and Reich’s access framework. We also evaluated PDPs’ capacity building in low- and middle-income countries at the individual, institutional, and system levels.We found that these PDPs advance public health by ensuring their products’ registration, distribution, and adoption into national treatment policies in disease-endemic countries. Nonetheless, ensuring broad, equitable access for these populations—high distribution coverage; affordability, particularly for the poor; and adoption at provider and end-user levels—remains a challenge.PRODUCT DEVELOPMENT partnerships (PDPs) are not-for-profit organizations that build partnerships between the public, philanthropic, academic, and private sectors to drive the development of new products for underserved markets and thereby improve health in low- and middle-income countries (LMICs). The PDP mission differs from that of the pharmaceutical industry, whose main objective is to maximize profits for shareholders by creating interventions for lucrative markets. Key features of the PDP model are a public health objective, use of the portfolio management approach, focus on a neglected disease target, and development of technical interventions (vaccines, drugs, or diagnostics). Yet PDPs vary on several parameters, including their core choice of disease and product targets, scope or breadth of activities (basic research, clinical research, access activities, capacity building), financial model, and operations model.1The World Health Organization recognizes that PDPs can contribute to the reduction of global health disparities.2 This idea has been reiterated by high-income country governments and influential organizations such as the United States’ Institute of Medicine, which identified the PDP platform as “one of the most promising approaches” to combat health disparities between and within countries.3^(p30),4 Accordingly, high-income country aid agencies, such as the US Agency for International Development and the United Kingdom’s Department for International Development, and philanthropic organizations have increasingly supported the PDP platform.5 Of the more than 60 existing drug projects for neglected diseases, three quarters are being performed by PDPs.6Despite their capacity to generate much-needed interventions for neglected diseases, PDPs are not without their critics. It has been suggested that the paradigm perpetuates research disparities and power inequities between high-income countries and LMICs. Financial control and decision-making power within PDPs rest with first-world head offices and senior staff primarily from the United States and Europe.7 We recently contended that because the majority of PDPs’ investment in research infrastructure and personnel goes to high-income countries, their ability to promote global health equity may be impaired.8For PDPs to improve the health of LMIC populations, it has been argued that they must not only develop new products for diseases identified as a priority by these countries but also, at a minimum, help to create access to their products and make meaningful efforts to strengthen research capacity.9,10 PDPs have expertise in the conduct of clinical research, making them an appropriate vehicle for capacity building in that area. PDPs can thus promote LMICs’ ability to one day conduct their own research to develop products for neglected diseases and to improve their health systems.Some PDPs appear to have recognized this and have expanded their scope to include access and capacity building. The access strategy of the Drugs for Neglected Diseases Initiative (DNDi) aims to facilitate a consistent and affordable treatment supply of DNDi products to LMICs; this entails ensuring rapid regulatory approval, making agreements with manufacturing partners, forecasting, ensuring supply to LMICs, and updating in-country treatment guidelines. Its strategy involves eventually shifting access activities for products to in-country champions.11 The access approach of the Medicines for Malaria Venture (MMV) is similar but involves an element—expanding reach—that could extend its role further than DNDi’s. Expanding reach means working with partners to achieve availability not just at the country level but also at the clinic level (point of use) and to ensure uptake by patients. Unlike DNDi, MMV’s strategy does not discuss an endpoint of involvement.12 In 2010, DNDi and MMV spent € 2.9 million (10.6% of total expenditure) and US $4.78 million (8.6% of total expenditure) on access and delivery, respectively.13,14 The Institute for One World Health (OWH) is undertaking access activities as well, although it does not have a formal access strategy. Both MMV and DNDi are involved in building research capacity in LMICs, but OWH is not. Even so, different objectives underlie DNDi and MMV’s research capacity–strengthening efforts. MMV sees capacity building as necessary for its performance of high-quality clinical trials; DNDi aims to contribute to the development of sustainable health research systems in LMICs.12,13Although MMV, DNDi, and OWH have expanded their scope to access and capacity building, some funders and even PDP board members have questioned the appropriateness and effectiveness of PDPs’ role in these areas, suggesting that they should focus solely on product development.15,16 Because most PDP products have only recently been launched, little investigation has been conducted into PDP achievements beyond product development to indicate whether such claims have substance. So far, PDPs have been evaluated against their success in financing and developing new vaccines and drugs, with their recent product approvals highlighted.5,6 Aside from acknowledging that listing these products on the World Health Organization’s Essential Medicine List does not amount to access,17 PDPs’ contribution to product accessibility or to research capacity strengthening in LMICs has undergone limited assessment.We examined the progress MMV, DNDi, and OWH have made in creating access to 8 of their recently launched products (Coartem Dispersible, Eurartesim, Pyramax, artesunate–amodiaquine [ASAQ], and artesunate–mefloquine [ASMQ] for malaria; nifurtimox–eflornithine combination therapy [NECT] for human African trypanosomiasis [HAT]; and paromomycin and sodium stibogluconate–paromomycin combination therapy for leishmaniasis). We selected these PDPs as the focus of our assessment because they are the first PDPs to have brought products to market.18 Relying on information derived from publicly available sources, we used the access framework developed by Frost and Reich to evaluate the 8 products for availability, affordability, and adoption.9 We assessed DNDi''s and MMV''s approaches to research capacity strengthening in LMICs for individual, institutional, and system achievements. This accords with a growing consensus that research capacity building at the country level requires strategies to be directed at these 3 distinct but complementary levels.10,19 We also compared PDPs’ access activities to those of the pharmaceutical industry to determine whether the 2 types of drug development organizations’ differing missions affected their access approaches.Because we only selected drug development PDPs for analysis, our conclusions may not reflect the approaches and achievements of vaccine development PDPs. Herman and Oudin argue that public health systems in LMICs are an adequate means of vaccine distribution to target populations.16 For certain vaccine PDPs, the GAVI Alliance also provides a centralized financing mechanism. As a result, access planning processes for new vaccines are potentially less complex and may require vaccine PDPs to take on fewer activities than do drug development PDPs.     

National Use of Asbestos in Relation to Economic Development

Background

National disparities in asbestos use will likely lead to an unequal burden of asbestos diseases.

Objectives

As economic status may be linked to asbestos use, we assessed, globally, the relationship between indicators of national economic development and asbestos use.

Methods

For the 135 countries that have ever used asbestos, per capita asbestos use (kilograms per capita per year) was compared with per capita gross domestic product (GDP) in 1990 Geary–Khamis dollars (GKD) for the period 1920–2003. Countries were grouped into three income levels (high, middle, and low) that were adapted from the 2003 World Bank categories.

Results

The historical pattern of asbestos use followed the environmental Kuznets curve in which use by high-income countries peaked when incomes attained 10,000–15,000 GKD and essentially ceased at income levels over 20,000 GKD. Currently, middle- and low-income countries are increasing their use of asbestos, closely following the paths once traced by higher income countries.

Conclusions

Developing countries have the opportunity to eliminate asbestos use sooner than high-income countries and thus reduce the future burden of asbestos diseases.     

Health system and societal barriers for gestational diabetes mellitus (GDM) services - lessons from World Diabetes Foundation supported GDM projects

Background

Maternal mortality and morbidity remains high in many low- and middle-income countries (LMIC). Gestational Diabetes Mellitus (GDM) represents an underestimated and unrecognised impediment to optimal maternal health in LMIC; left untreated – it also has severe consequences for the offspring. A better understanding of the barriers hindering detection and treatment of GDM is needed. Based on experiences from World Diabetes Foundation (WDF) supported GDM projects this paper seeks to investigate societal and health system barriers to such efforts.

Methods

Questionnaires were filled out by 10 WDF supported GDM project partners implementing projects in eight different LMIC. In addition, interviews were conducted with the project partners. The interviews were analysed using content analysis.

Results

Barriers to improving maternal health related to GDM nominated by project implementers included lack of trained health care providers - especially female doctors; high staff turnover; lack of standard protocols, consumables and equipment; financing of health services and treatment; lack of or poor referral systems, feedback mechanisms and follow-up systems; distance to health facility; perceptions of female body size and weight gain/loss in relation to pregnancy; practices related to pregnant women’s diet; societal negligence of women’s health; lack of decision-making power among women regarding their own health; stigmatisation; role of women in society and expectations that the pregnant woman move to her maternal home for delivery.

Conclusions

A number of barriers within the health system and society exist. Programmes need to consider and address these barriers in order to improve GDM care and thereby maternal health in LMIC.

     

Equity of primary care service delivery for low income “sicker” adults across 10 OECD countries

Background

Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally.

Methods

The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent.

Results

Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands.

Conclusion

Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector.

     

Incorporating MCDA into HTA: challenges and potential solutions,with a focus on lower income settings

Background

Multicriteria decision analysis (MCDA) has the potential to bring more structure and transparency to health technology assessment (HTA). The objective of this paper is to highlight key methodological and practical challenges facing the use of MCDA for HTA, with a particular focus on lower and middle-income countries (LMICs), and to highlight potential solutions to these challenges.

Methodological challenges

Key lessons from existing applications of MCDA to HTA are summarized, including: that the socio-technical design of the MCDA reflect the local decision problem; the criteria set properties of additive models are understood and applied; and the alternative approaches for estimating opportunity cost, and the challenges with these approaches are understood.

Practical challenges

Existing efforts to implement HTA in LMICs suggest a number of lessons that can help overcome the practical challenges facing the implementation of MCDA in LMICs, including: adapting inputs from other settings and from expert opinion; investing in technical capacity; embedding the MCDA in the decision-making process; and ensuring that the MCDA design reflects local cultural and social factors.

Conclusion

MCDA has the potential to improve decision making in LMICs. For this potential to be achieved, it is important that the lessons from existing applications of MCDA are learned.

     

Synergies,strengths and challenges: findings on community capability from a systematic health systems research literature review

Background

Community capability is the combined influence of a community’s social systems and collective resources that can address community problems and broaden community opportunities. We frame it as consisting of three domains that together support community empowerment: what communities have; how communities act; and for whom communities act. We sought to further understand these domains through a secondary analysis of a previous systematic review on community participation in health systems interventions in low and middle income countries (LMICs).

Methods

We searched for journal articles published between 2000 and 2012 related to the concepts of “community”, “capability/participation”, “health systems research” and “LMIC.” We identified 64 with rich accounts of community participation involving service delivery and governance in health systems research for thematic analysis following the three domains framing community capability.

Results

When considering what communities have, articles reported external linkages as the most frequently gained resource, especially when partnerships resulted in more community power over the intervention. In contrast, financial assets were the least mentioned, despite their importance for sustainability. With how communities act, articles discussed challenges of ensuring inclusive participation and detailed strategies to improve inclusiveness. Very little was reported about strengthening community cohesiveness and collective efficacy despite their importance in community initiatives. When reviewing for whom communities act, the importance of strong local leadership was mentioned frequently, while conflict resolution strategies and skills were rarely discussed.Synergies were found across these elements of community capability, with tangible success in one area leading to positive changes in another. Access to information and opportunities to develop skills were crucial to community participation, critical thinking, problem solving and ownership. Although there are many quantitative scales measuring community capability, health systems research engaged with community participation has rarely made use of these tools or the concepts informing them. Overall, the amount of information related to elements of community capability reported by these articles was low and often of poor quality.

Conclusions

Strengthening community capability is critical to ensuring that community participation leads to genuine empowerment. Our simpler framework to define community capability may help researchers better recognize, support and assess it.

     

Population aging,macroeconomic changes,and global diabetes prevalence, 1990–2008

Background

Diabetes is an important contributor to global morbidity and mortality. The contributions of population aging and macroeconomic changes to the growth in diabetes prevalence over the past 20 years are unclear.

Methods

We used cross-sectional data on age- and sex-specific counts of people with diabetes by country, national population estimates, and country-specific macroeconomic variables for the years 1990, 2000, and 2008. Decomposition analysis was performed to quantify the contribution of population aging to the change in global diabetes prevalence between 1990 and 2008. Next, age-standardization was used to estimate the contribution of age composition to differences in diabetes prevalence between high-income (HIC) and low-to-middle-income countries (LMICs). Finally, we used non-parametric correlation and multivariate first-difference regression estimates to examine the relationship between macroeconomic changes and the change in diabetes prevalence between 1990 and 2008.

Results

Globally, diabetes prevalence grew by two percentage points between 1990 (7.4 %) and 2008 (9.4 %). Population aging was responsible for 19 % of the growth, with 81 % attributable to increases in the age-specific prevalences. In both LMICs and HICs, about half the growth in age-specific prevalences was from increasing levels of diabetes between ages 45–65 (51 % in HICs and 46 % in LMICs). After age-standardization, the difference in the prevalence of diabetes between LMICs and HICs was larger (1.9 % point difference in 1990; 1.5 % point difference in 2008). We found no evidence that macroeconomic changes were associated with the growth in diabetes prevalence.

Conclusions

Population aging explains a minority of the recent growth in global diabetes prevalence. The increase in global diabetes between 1990 and 2008 was primarily due to an increase in the prevalence of diabetes at ages 45–65. We do not find evidence that basic indicators of economic growth, development, globalization, or urbanization were related to rising levels of diabetes between 1990 and 2008.

     

Financial hardship on the path to Universal Health Coverage in the Gulf States

Background

Countries globally are pursuing universal health coverage to ensure better healthcare for their populations and prevent households from catastrophic expenditure. The countries of the Gulf Cooperation Council (GCC) have and continue to implement reforms to strengthen their health systems. A common theme between the countries is their pursuit of universal health coverage to provide access to necessary health care without exposing people to financial hardship.