A sustainability assessment of a health equity fund initiative in Cambodia

All but one of the health equity funds (HEFs) currently operating in Cambodia, introduced to address the adverse effects of low user fee exemption rates, rely heavily on external funding and have high administrative overheads. This article reports on a study of one type of HEF, based in Kirivong Operational Health District (KOD) and operated through local pagoda structures, which demonstrates minimal reliance on external funding and low administrative overheads. We utilize an adapted sustainability assessment framework to assess the ability of pagoda structures to enable financial access for the poorest to public sector health services. We further analyse the strengths and limitations of the pagoda-managed equity fund initiative, with a view to assessing not only its sustainability but its potential for replication in other settings.Our study shows that, against key sustainability indicators (health service utilization and health outcomes; management capacity and financial viability; community mobilization and government support), the pagoda-managed equity fund initiative scores well. However, it is evident that some external financial support is needed to allow the HEFs to function effectively. We conclude with recommendations for replicating the initiative, which include working innovatively with indigenous grassroots organizations to enhance community HEF ownership and to keep administrative overheads low.     

北京市1985～1995年计划免疫接种率监测分析

本文对北京市1985～1995年间计划免疫接种率监测资料与相应传染病发生情况进行比较分析,结果显示免疫接种率达到一定高度的水平时,相应传染病发生率呈急剧下降;免疫接种率与相应传染病呈高度负相关;政府参与、领导重视、报告系统完善、各部门协调和家长对计划免疫的态度等是保持合格免疫接种率高水平的重要影响因素。     

Sustained use of a household-scale water filtration device in rural Cambodia

The effectiveness of point-of-use water treatment may be limited by declining use over time, particularly when water treatment is introduced via targeted intervention programmes. In order to evaluate the long-term uptake and use of locally produced ceramic water filters in rural Cambodia, we visited households that had received filters as part of NGO-subsidized distribution programmes over a 4 year period from 2002 to 2006. Of the more than 2,000 filters distributed, we visited 506 randomly selected households in 13 villages spanning three provinces to assess filter time in use and to collect data on factors potentially correlated with long-term use. Results indicate that filter use declined at the rate of approximately 2% per month after implementation, largely owing to breakages, and that, controlling for time since implementation, continued filter use over time was most closely positively associated with: related water, sanitation and hygiene practices in the home; cash investment in the technology by the household; and use of surface water as a primary drinking water source.     

Financial costs of deworming children in all primary schools in Cambodia

In 2002, Cambodia's Ministry of Health launched a deworming programme to deliver an anthelmintic drug (mebendazole 500 mg) and health education to 75% of its school children twice a year. Cambodia's school population is approximately 2.8 million. The deworming programme was organized into two phases: the first phase (December 2002-March 2003) targeted more than one million school children from 11 provinces; and the second phase (July 2003-January 2004) targeted the entire school population. The cost to treat each child was 12 cents (0.11 USD) during the first phase, 6 cents during the second phase, and 3 cents for re-treatment in areas where the campaign was conducted for the second time. The Cambodian experience demonstrates that, with political commitment, high coverage for deworming is achievable even in a country with minimal resources. Cambodia's deworming programme represents a successful model for other developing countries.     

浙江省1978—2007年计划免疫卫生经济学评价

目的：科学评价浙江省实施计划免疫工作三十年来取得的成绩,进一步提高资源配置及服务效率,促进免疫规划工作的可持续发展。方法：以项目分摊方法开展对省、市及8个样本县计划免疫投入成本调研,采用ARIMA模型（Autoregressive Integrated MovingAverage Model,自回归移动平均模型）拟合脊灰、麻疹等7种疫苗针对传染病理论发病水平,结合专家论证测算疾病负担和经济效益,再用成本效果分析（Cost Effectiveness Analysis,CEA）、成本效益分析（Cost Benefit Analysis,CBA）和成本效用分析（Cost Utility Analysis,CUA）等开展评价。结果：实施计划免疫工作三十年来,浙江省减少脊灰、麻疹等7种疫苗针对传染病发病5645087人、减少死亡190748人,取得的效益合计为19．14亿元,浙江省计划免疫三十年的成本效果比（CEA）为每万元：减少67人发病及减少2人死亡、成本效益比（CBA）为1：21．31、成本效用比（CUA）为1万元：70．63DALY,分病种评价中各项指标均麻疹最高。结论：自1978年实施计划免疫工作以来,浙江省有效控制了各种疫苗针对性传染病,取得了巨大的社会经济效益。为做好免疫规划工作的可持续发展,建议继续建立稳定的筹资与投入保障机制,并着重加强麻疹等成本效益显著疾病的防控工作并适时扩大免疫规划。     

儿童计划免疫疾病抗体水平与报告接种率比较

目的了解儿童麻疹、白喉、脊髓灰质炎等计划免疫疾病的抗体水平、抗体阳性率与报告接种率吻合程度。方法抽取湖南省1个县10个乡镇中2001~2003年出生儿童253名,比较各年出生儿童血清中麻疹、白喉、脊灰抗体阳性率、抗体滴度,比较抗体阳性率与报告接种率的关系。结果麻疹、白喉、脊髓灰质炎抗体阳性率分别为87.0%,42.9%,87.0%,均低于报告免疫接种率（P〈0.01）。结论要警惕百白破三联疫苗接种率低的现象,可考虑开展接种率抽样调查的同时辅以血清学调查的综合审评方法评价免疫规划疫苗的接种率情况。     

鄂尔多斯市乙肝疫苗接种免疫服务状况调查

目的了解我市预防接种服务现状。方法采用整群分层抽样方法,用EPI-data软件处理数据,用SPSS软件统计分析。结果全市预防接种管理机构管理状况尚处于一般水平,能主动开展宣传培训督导工作,管理人员平均年龄偏大。接生机构管理存在一定问题,主要表现在疫苗管理、主动宣传等。结论加强对预防接种管理机构和接生机构的督导考核和培训,加强乙肝知识的宣传是进一步提高儿童乙肝疫苗接种率的关键。     

Routine immunization services costs and financing in China, 2015

ObjectiveTo estimate the costs of routine immunization (RI) services in China in 2015, to provide objective data relevant to investment in the Expanded Program on Immunization, and to contribute to global data on costing and financing of RI.MethodsThe study was conducted between January and March 2016. We selected 276 villages, 138 townships, 46 counties, and 40 prefectures from 15 provinces as investigation sites at random, stratified by eastern, middle, and western regions. Direct cost items included vaccines, personnel, cold chain, surveillance, communication, training, and supervision at the national, provincial, prefecture, county, township, and village levels. We obtained financial data from governmental and external sources. Indirect costs of RI included parents’ transportation costs and productivity lost due to taking their children for vaccination.ResultsTotal direct costs were $92.42 for each child fully immunized ($4.20/dose), which equates to $1529.55 million per birth cohort. RI costs were higher in the eastern region than in the western region, and higher than that of the central region. Vaccination coverage was positively associated with direct routine immunization costs. The cost of the recommended vaccines was $19.08/child and vaccine only accounted for 20.64% of total costs. Operational cost, including surveillance, communication, training and supervision, was $217.31/child, accounting for 14.21% of total cost. The indirect cost per child was $72.86; the total indirect cost was $1205.83 million for the birth cohort. Government investment in RI accounted for about 70% of total costs. Revenue from sales of private-sector vaccine supported the remaining 30% of RI costs.ConclusionsWhile government financing has increased, some operating costs continue to be provided from revenue generated by sales of Category 2 (private-sector) vaccines to families. China could benefit from bringing new and underutilized vaccines into the EPI system based on evidence that includes routine immunization vaccine and operations costs.     

Ownership and financial sustainability of German acute care hospitals

This paper considers the role of ownership form for the financial sustainability of German acute care hospitals over time. We measure financial sustainability by a hospital-specific yearly probability of default (PD) trying to mirror the ability of hospitals to survive in the market in the long run. The results show that private ownership is associated with significantly lower PDs than public ownership. Moreover, path dependence in the PD is substantial but far from 100%, indicating a large number of improvements and deteriorations in financial sustainability over time. Yet, the general public hospitals have the highest path dependence. Overall, this indicates that public hospitals, which are in a poor financial standing, remain in that state or even deteriorate over time, which may be conflicting with financial sustainability.     

基于网格化管理下的流动儿童计划免疫接种率调查及其影响因素分析

目的 了解深圳市某社区0～6岁儿童免疫规划的接种率,分析影响流动儿童免疫接种的主要因素,并结合网格化管理探讨流动儿童计划免疫管理工作的新方案。 方法 利用普查的方法对该社区6周岁以内的儿童进行免疫接种情况调查,并随机抽取部分儿童家长进行问卷调查以探索其影响因素。 结果 儿童卡介苗(BCG)、乙肝全程(HepB3)、脊灰三次(OPV3)、脊灰④(OPV4)、百白破三次(DPT3)、百白破④(DPT4)、麻疹①(MV1)、麻疹②(MV2)、乙脑①(JE1)、乙脑②(JE2)、A群流脑两次(MenA2)、A+C群流脑①(MenA1)、甲肝(HepA)的接种率分别为99.57%、95.57%、94.36%、61.48%、95.69%、86.19%、89.43%、88.89%、96.93%、87.36%、92.70%、72.64%、87.83%。非条件Logistic逐步回归显示,儿童出生具体地点、父亲文化程度、是否知道儿童入园入学要凭接种证开查验证明是影响儿童接种的主要因素。 结论 提高流动儿童计划免疫接种率的关键在于建立有效的计划免疫管理模式,提高家长对儿童计划免疫的认识,加强儿童2周岁后疫苗接种的通知与宣传发动工作。     

Decentralizing EPI services and prospects for increasing coverage: the case of Tanzania

Primary health Care (PHC) strategies were adopted widely in 1978 after the Alma Ata declaration to improve accessibility to health services and the health of the people. Of the strategies of PHC was the decentralization of health services to lower levels in order to enhance participation and responsiveness of the health system to local problems. While PHC was being promoted vertical programmes such as the expanded programme on immunization (EPI) were also being promoted and achieved substantial benefits. However, almost 25 years later many countries have not been able to achieve these health goals. This study addressed the question: Can we make the process of health care decentralization more likely to support health system and EPI goals? This study analysed the experience of EPI decentralization at national, regional and district levels. Several stakeholders were identified who were supportive and others who were non‐supportive of the process. Community support to EPI measured by using willingness to pay (WTP) for kerosene (to keep vaccines cool) was low. It was significantly (p < 0.05) associated with whether providers in the nearest health facility properly attended the target population and whether the providers in the facility were available when needed. There was a substantial stakeholder support and opposition to the process of decentralization at the district level. Community support was not high possibly due to the perceived non‐availability of the service providers and their lack of awareness of the population they serve. It was proposed that reforms should give priority to the involvement of communities and peripheral health facility providers in the process. Copyright © 2005 John Wiley & Sons, Ltd.     

The uptake of childhood immunization and financial incentives to general practitioners

Among the target-linked services introduced by the 1990 general practitioners' contract, childhood immunization in Scotland is the best suited for GPs to achieve the high target, given a centralized call and recall system and public confidence in the service. Yet over 25% of the practices in the area of the Greater Glasgow Health Board did not qualify for the high target payments in the last quarter of the 1991/92 financial year. Examining indicators of the socioeconomic characteristics of the patient population, practice profiles and the effect of financial incentives, we discuss the reasons for cross-practice variation in the uptake of this service and estimate the probability of practices which missed the high target achieving it in the future.     

Determinants of utilisation of intrapartum obstetric care services in Cambodia,and gaps in coverage

Abstract

Background. Facility delivery and skilled birth attendance are two of the most effective strategies for decreasing maternal mortality. The objectives of this study were to further define utilisation of these services in Cambodia and to uncover socio-economic or location-specific coverage gaps that may exist.

Methods. We performed a cross-sectional analysis of the 2005 Cambodia Demographic Health Survey (CDHS) to determine prevalence, and determinants, of service utilisation.

Results. Out of 6069 women aged 15–49 years, 77% delivered at home, three-fourths without a skilled birth attendant. Poverty, lower education and rural residence were associated with the highest likelihood of poor utilisation of services.

Discussion. While there has been an overall increase in facility deliveries and skilled birth attendance since 2000, improvements have been spread unevenly across the population, benefiting mostly urban, wealthier and better educated women. While recent financing initiatives and health system developments appear to have further increased service utilisation since 2005, the extent of their reach to the most vulnerable populations, and their ultimate impact on maternal mortality reduction, remain to be elucidated.

Conclusion. Further expanding successful initiatives, particularly among vulnerable populations, is essential. Longitudinal evaluation of ongoing strategies and their impact remains critical.     

国外预防接种服务及对我国农村地区的启示

预防接种被认为是经济、有效、方便的提高易感人群免疫水平及预防传染性疾病的公共卫生干预措施.目前,我国预防接种工作,尤其是农村地区的免疫接种率有所下降,有些传染病有死灰复燃的趋势.该文通过对几个国家预防接种服务特点和经验的介绍,试图总结出我国农村地区预防接种服务存在的问题,并借鉴其他国家的经验提出相关政策建议.     

Abortion incidence in Cambodia, 2005 and 2010

Although Cambodia now permits elective abortion, scarcity of research on this topic means that information on abortion incidence is limited to regional estimates. This estimation model combines national survey data from Demographic and Health Surveys (DHS) with national prospective data of abortion procedures from government health facilities, collected in 2005 and 2010, to calculate the national incidence of safe and unsafe abortion. According to DHS, the proportion of all induced abortions that took place in a health facility in the five years preceding each survey increased from almost 52% to 60%. Projecting from facility-based abortions to national estimates, the national abortion rate increased from 21 to 28 per 1000 women aged 15–44. The abortion ratio also increased from 19 to 28 per 100 live births. This research quantifies an increase in safely induced abortions in Cambodia and provides a deeper understanding of induced abortion trends in Cambodia.     

社区流动儿童计划免疫服务干预模式效果评估

目的探讨“村公共卫生服务员管理”模式对社区流动儿童计划免疫服务综合干预的效果。方法随机抽取本社区6个村中暂住时间〉3个月的1～6周岁流动儿童为干预对象。选择葑村、红光等4个村的流动儿童作为试验组，实施“村公共卫生服务员管理”计划免疫服务模式干预2年，另选五星、三星村作为对照组。结果于2005（干预前）、2006（干预1年）和2007年（干预2年）在试验组分别调查流动儿童212、230和248名，调查对象在3个年份间的预防接种建证率差异有统计学意义（P〈0．05），五苗接种率差异也有统计学意义（P〈0．01）。结论建立“村公共卫生服务员管理”模式，有助于提高社区流动儿童免疫建证及接种率。     

Iodized Salt in Cambodia: Trends from 2008 to 2014

Though the consequences of nutritional iodine deficiency have been known for a long time, in Cambodia its elimination has only become a priority in the last 18 years. The Royal Government of Cambodia initiated the National Sub-Committee for Control of Iodine Deficiency Disorders in 1996 to fight this problem. Using three different surveys providing information across all provinces, we examined the compliance of salt iodization in Cambodia over the last 6 years. Salt samples from the 24 provinces were collect at the household level in 2008 (n = 566) and 2011 (n = 1275) and at the market level in 2014 (n = 1862) and analysed through a wavelength spectrophotometer for iodine content. According to the samples collected, the median iodine content significantly dropped from 22 mg/kg (25th/75th percentile: 2/37 mg/kg) in 2011 to 0 mg/kg in 2014 (25th/75th percentile: 0/8.9 mg/kg) (p < 0.001). The proportion of non-iodized salt within our collected salt drastically increased from 22% in 2011 to 62% in 2014 (p < 0.001). Since the international organizations ceased to support the procurement of iodine, the prevalence of salt compliant with the Cambodian declined within our samples. To date, the current levels of iodine added to tested salt are unsatisfactory as 92% of those salts do not meet the government requirements (99.6% of the coarse salt and 82.4% of the fine salt). This inappropriate iodization could illustrate the lack of periodic monitoring and enforcement from government entities. Therefore, government quality inspection should be reinforced to reduce the quantity of salt not meeting the national requirement.     

Nipah virus in Lyle's flying foxes, Cambodia

We conducted a survey in Cambodia in 2000 on henipavirus infection among several bat species, including flying foxes, and persons exposed to these animals. Among 1,072 bat serum samples tested by enzyme-linked immunosorbent assay, antibodies reactive to Nipah virus (NiV) antigen were detected only in Pteropus lylei species; Cynopterus sphinx, Hipposideros larvatus, Scotophilus kuhlii, Chaerephon plicata, Taphozous melanopogon, and T. theobaldi species were negative. Seroneutralization applied on a subset of 156 serum samples confirmed these results. None of the 8 human serum samples was NiV seropositive with the seroneutralization test. One virus isolate exhibiting cytopathic effect with syncytia was obtained from 769 urine samples collected at roosts of P. lylei specimens. Partial molecular characterization of this isolate demonstrated that it was closely related to NiV. These results strengthen the hypothesis that flying foxes could be the natural host of NiV. Surveillance of human cases should be implemented.     

Serologic evidence of lyssavirus infection in bats, Cambodia

In Cambodia, 1,303 bats of 16 species were tested for lyssavirus. No lyssavirus nucleocapsid was detected in 1,283 brains tested by immunofluorescence assay. Antibodies against lyssaviruses were detected by enzyme-linked immunosorbent assay in 144 (14.7%) of 981 serum samples. Thirty of 187 serum samples contained neutralizing antibodies against different lyssaviruses.     

Burkholderia pseudomallei antibodies in children, Cambodia

Antibodies to Burkholderia pseudomallei were detected in 16% of children in Siem Reap, Cambodia. This organism was isolated from 30% of rice paddies in the surrounding vicinity. Despite the lack of reported indigenous cases, melioidosis is likely to occur in Cambodia.