Alongside endorsing Millennium Development Goal 5 in 2000, India launched its National Population Policy in 2000 and the National Health Policy in 2002. However, these have failed thus far to reduce the maternal mortality ratio (MMR) by the targeted 5.5% per annum. Under the banner of the National Rural Health Mission, the Government of India launched a national conditional cash transfer (CCT) scheme in 2005 called Janani Suraksha Yojana (JSY), aimed to encourage women to give birth in health facilities which, in turn, should reduce maternal deaths. Poor prenatal care in general, and postnatal care in particular, could be considered the causes of the high number of maternal deaths in India (the highest in the world). Undoubtedly, institutional delivery in India has increased and MMR has reduced over time as a result of socioeconomic development coupled with advancement in health care including improved women’s education, awareness and availability of health services. However, in the light of its performance, we argue that the JSY scheme was not well enough designed to be considered as an effective pathway to reduce MMR. We propose that the service-based CCT is not the solution to avoid/reduce maternal deaths and that policy-makers and programme managers should reconsider the ‘package’ of continuum of care and maternal health services to ensure that they start from adolescence and the pre-pregnancy period, and extend to delivery, postnatal and continued maternal health care.

Background: Japanese encephalitis (JE) is a major public health problem in India. When the first case was reported in 1955, the disease was restricted to south India. The disease spread to north India in 1978 from where extensive and recurrent outbreaks of JE have been reported ever since. An attempt has been made to review the epidemiology of JE over the past 30 years and suggestions made for its prevention and control. Methods: An epidemiological profile of JE (1978–2009) has been compiled and analysed to understand the trend and status of the disease. Results: In India, while 24 states are endemic for JE, Uttar Pradesh contributed more than 75% of cases during the recent past. Over the years, the seasonal trend has changed and the epidemic peak of the disease has advanced by one month. Conclusion: JE is closely associated with the pattern of precipitation, flooding and rice production systems. Analysis of trends and influencing factors will help in designing suitable strategies for the prevention and control of JE in the country. Continuous monitoring of vector populations and JE virus infection rates in vector mosquitoes will help in predicting an outbreak and in taking effective intervention measures.

Visceral leishmaniasis (kala-azar) continues to be a major rural public health problem in Bangladesh. A cross-sectional study was carried out in two subdistricts of Mymensingh district from January 2006 to June 2007 to evaluate the delay kala-azar treatment. Suspected patients who attended to out patient department (OPD) were subjected to a dipstick test (RK39) for kala-azar. Sixty five from Bhaluka and 60 positive patients from Gafargaon subdistrict were enrolled. Most of the patients (80%) first visited nonqualified private practitioners, while only 15.2% consulted registered doctors. Fifty per cent were referred to the Upazilla health complex (UZHC) by the family members or relatives. About 49% and 43% patients required third and second health-care providers for kala-azar treatment, respectively. Patient delay ranged from 2 to 30 days; median 4 (IQR 3 to 7 days), the system delay ranged from 0 days to 225 days; median 54 (IQR 40–66 days). Residential status (p value <0.05) had impact on patient delay. Educational status and number of treatment providers had impact on system delay (p<0.05). System delay rather than patient delay is the important weakness of the kala-azar control programme in Bangladesh. Residence in rural areas, low educational background and treatment providers are associated with these delays. A proper educational programme may reduce the delay.

Background: Tuberculosis is the leading cause of deaths among HIV patients. In this study, we estimated the prevalence of pulmonary tuberculosis (PTB) and identified the factors/co-morbidities associated with active PTB in HIV-infected people visiting the national public health laboratory to assess their eligibility to receive highly active antiretroviral therapy. Methods: A cross-sectional study was conducted to measure the prevalence of pulmonary tuberculosis. Data on probable risk factors in patients with and without PTB were compared, calculating the odds ratio as a measure of association. Factors showing significant association in univariate analyses were included in a stepwise backward logistic regression model to adjust for confounding. Results: The prevalence of pulmonary tuberculosis was 32.4 % (95% confidence interval (CI) 30.25–34.56). In the univariate analysis, patients with PTB were more likely to be older, married, and have a longer duration since the diagnosis of HIV, diarrhoea, parasitic infection, lower CD4 T-cell counts, and lower CD4/CD8 ratio. However, the backward stepwise logistic regression revealed that only the CD4 T-cell count < 200/μL (AOR 11.69, 95% CI 6.23–21.94), CD4 T-cell count 200–350/μL (AOR 2.52, 95% CI 1.30–4.89), diarrhoea (AOR 2.77, 95% CI 1.78–4.31), parasitic infection (AOR 3.34, 95% CI 2.02–5.50) and ‘sex with partner’ as probable modes of transmission (AOR 0.44, 95% CI 0.20–0.93) were independently associated with pulmonary tuberculosis. Conclusion: A high prevalence of pulmonary tuberculosis was observed. Participants with tuberculosis were significantly more likely to have lower CD4 counts, diarrhoea, and parasitic infections. HIV treatment programmes should consider these factors for better outcomes.

Background: In Thailand, the 2008 Alcoholic Beverages Control Act set the minimum purchase age (MPA) at 20 years old in order to limit new drinkers as part of the overall alcohol control effort. This study aims to assess the compliance of off-premise alcohol retailers with MPA restrictions and to identify factors affecting sales to adolescents. Methods: A decoy protocol was used to quantify compliance of 417 alcohol retailers from three categories, namely grocers, modern minimarts and department stores. Multi-stage sampling was applied to obtain the samples in four provinces: Bangkok, Nakorn Sawan, Songkhla and Surin. Each alcohol retailer was visited twice by 17–19 year-old male and female adolescents who tried to buy alcohol. Information collected from focus groups and in-depth interviews with vendors and management officers were analysed for the qualitative methodology. Results: Of all 834 buying attempts undertaken by the underage adolescent, 98.7% were successful in buying alcohol. Only 0.9% were asked for age and 0.1% were requested to show an ID card. Age and ID verifications were statistically significant to buying success as well as province, while number of vendors, gender and age of vendors and buyers, type of outlet, law cautions and advertisement signs in the outlet demonstrated no significant association. Conclusions: The results showed that vendors fail to comply with the law despite the fact that they know the law. Enforcement needs to be strengthened to effectively limit new drinkers.

Background: The quality of blood transfusion services (BTS) is essential for the treatment of patients who need blood or blood products. BTS involve several steps, including the acquisition of the donor’s blood, blood grouping, unexpected antibody screening, blood storage, transfusion, etc. There is a need to check the effectiveness of all elements in the BTS can be assessed and monitored by an external quality assessment. Aim: To assess and evaluate the performance of ABO and Rh(D) blood grouping and unexpected antibody screening of the selected World Health Organization (WHO) South-East Asia Region Member country laboratories. Methods: WHO Collaborating Centre on Strengthening Quality of Health Laboratories (Thailand) organized a regional external quality assessment scheme for blood group serology (REQAS-BGS) between 2002 and 2008 for laboratories in countries of the WHO South-East Asia Region. Test items for ABO and Rh(D) blood groupings and unexpected antibody screening and identification were distributed three cycles per year to BTS laboratories in Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. By the end of the project, a total of 20 BTS laboratories had participated for differing lengths of time. Results: It was found that 87.5%, 93.3%, 81.3%, 92.3%, 100% and 87.5% of laboratories returned the test results in 2002, 2003, 2004, 2006, 2007 and 2008, respectively. Laboratories with excellent quality or a trend of quality improvement for ABO and Rh(D) blood grouping, unexpected antibody screening and identification during the six years were 60% (12/20), 50% (10/20), 52.9% (9/17) and 81.8% (9/11), respectively. At the initiation of the scheme, most laboratories were using substandard methods for ABO and Rh blood groupings, i.e. performing only direct blood grouping alone but subsequently adopted the standard methods, i.e. performing both direct and reverse blood groupings. Conclusion: REQAS-BGS in South-East Asia countries has been useful for assessing, monitoring and improving the quality of testing. Challenges such as high costs and regulatory requirements for international shipment of blood samples could be solved by amending the regulation(s) for shipment, or establishing a national EQAS.

Background: Rotavirus as a causative agent of childhood diarrhea is known to cause serious illness among children less than 5 years of age. This study examined the epidemiology of rotavirus disease burden and diversity of G and P genotypes of rotavirus in Nepal. Methods: Stool samples were tested for rotavirus by Enzyme Immuno Assay and Group A rotaviruses were detected by using both ELISA and RT-PCR in 2718 samples between 2009 and 2011. Results: Rotavirus was more frequently detected among inpatients (28.5%) than outpatients (15.2%). Over the three-year study period, 653 (24.4%) cases were positive for rotavirus by ELISA. Genotyping by RT-PCR was done on 638 samples. The most prevalent genotype was G12P [6] (60.4%). Mixed infections were not uncommon (14% in 2009, 29% in 2010 an 7% in 2011). However, 41 were partially typed and 23 were completely untyped over the study period. Conclusions: This study highlights the rotavirus disease burden and diversity of rotavirus strains circulating in Nepal. Continued sentinel surveillance will provide useful information to policy makers with regard to rotavirus vaccine introduction.

Objectives: Cervical cancer is the commonest malignancy among women in Nepal but data are limited on which subtypes of human papillomavirus (HPV) are associated with cancer in this population. Now that vaccines against HPV types 16 and 18 are available, this evidence is of vital importance in obtaining further support for a vaccination programme. Methods: Cervical swabs from 44 histologically confirmed invasive cervical cancer cases were obtained from two tertiary referral hospitals in Nepal. Evidence of HPV subtypes was identified using an HPV multiplex polymerase chain reaction (PCR), and confirmed at the Scottish HPV Virus Reference Laboratory. Results: HPV types 16 and 18 were present in 70% of samples, along with other high-risk subtypes. HPV 6 and 11 were not observed. Epidemiological data assessment appeared to indicate that patient age, age of marriage and age of first pregnancy were associated with increased HPV infection in patients. Conclusions: This study provides further evidence of the importance of HPV types 16 and 18 in cervical cancer in Nepal and adds support to a nationwide vaccination programme and the use of HPV detection in screening programmes.

Background: An Infant Death Review (IDR) programme was developed and implemented in two districts of Karnataka. Objective: We explored the processes that led to the development of the IDR programme with a view to improving the existing pilot programme and to ensuring its sustainability. Methods: A sequential mixed-methods design was followed in which quantitative data collection (secondary data) was followed by qualitative data collection (in-depth interviews). Quantitative data were entered using EpiInfo (version 3.5.1) software and qualitative data were analysed manually. Results: Apart from ascertaining the cause of infant deaths, the IDR Committee discusses social, economic, behavioural and health system issues that potentially contribute to the deaths. As a result of the IDR programme, key actors perceived an improvement in infant death reporting at district level, the development of a rapport with the local community, and elaboration of a feedback system for corrective actions. This has led to improved health care during pregnancy. Conclusions: We found that involvement of the different stakeholders in planning and implementing the IDR programme offered a platform for collective learning and action. Impediments to the success of the programme need to be addressed by corrective actions at all levels for its future sustainability.

Background: The World Health Organization has described health systems responsiveness (HSR) as a multi-domain concept encompassing eight non-medical expectations of health-care service seekers. HSR is a valuable measure of health systems performance, providing policy-makers and service providers much information to improve services. This paper presents findings of a cross-sectional survey conducted to assess HSR and its correlates through family planning (FP) services in Colombo district, Sri Lanka. Methods: A Health Systems Responsiveness Assessment Questionnaire, developed and validated in Sri Lanka, was used. Trained interviewers administered the questionnaire in 38 FP clinics randomly selected to sample 1520 clients. Results: The rating of responsiveness as ‘good’ for six domains ranged from 88% (n=1338) to 72% (n=1094). The overall HSR was rated to be ‘good’ by 83.4% (1268). Ethnicity being majority Sinhalese, persons who were currently employed and those using oral contraceptive pills (OCP) or condoms were negatively associated with rating of HSR. Positive associations with the HSR assessment were a family income of less than Rs 40 000 (US$ 303) per month, satisfaction with current FP method, use of only one method within the past year, use of only one FP clinic within the past year, health service provider being a medical officer, intention to use the FP clinic services in future, and satisfaction with overall services of the clinic. Conclusions: Though overall HSR was rated by the majority as ‘good’, some aspects need more attention in delivering FP services.

Background: In Myanmar a large proportion of antenatal and intrapartum care in rural areas is provided by skilled birth attendants (SBAs), this study assessed the coverage by these health workers of all births, their adherence to service guidelines, and community opinion on the antenatal and delivery care they give in two rural health centres in Pathein Township, Ayeyarwaddy Region to identify the challenges and improve antenatal and intrapartum service delivery provided by the SBAs. Method: A structured questionnaire was used to interview 304 women who had infants under one year of age, and in-depth interviews were held with 12 SBAs and 10 community members. Results: Of the 304 pregnancies, 93% had received antenatal care (ANC); 97% of these were covered by SBAs at an average 15 weeks’ gestation. The average frequency of ANC visits was 9. Rates of home and hospital deliveries were 84.5% and 13.8% respectively. Among home deliveries, use rate of SBA was 51.4%, while for postnatal care, 31.3% was given by unskilled providers (traditional birth attendants (TBAs) 17.5%, auxiliary midwives (AMWs),13.8%). Multivariate analysis showed that interviewees aged 30 years and below (OR=0.468, P=0.046), with an education at primary level and below that of husband (OR=0.391, P=0.007) or not residing in the village of the rural/station health centre (OR=0.457, P=0.011) were significantly less likely to use SBAs. The categories of supervision, referral, and health education activities of SBAs were not in line with service guidelines. The main reasons were lack of access and community acceptance of TBAs. Conclusion: Heavy workload, geographical location, transportation and financial concerns were major challenges for SBAs, along with community compliance and mutual coordination. Good communication and service management skills were important to overcome these challenges.