WHO South-East Asia Journal of Public Health
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   2014| July-December  | Volume 3 | Issue 3  
    Online since May 23, 2017

 
 
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ORIGINAL RESEARCH
Mothers' caregiving resources and practices for children under 5 years in the slums of Hyderabad, India: a cross-sectional study
Rajini Peter, K Anil Kumar
July-December 2014, 3(3):254-265
DOI:10.4103/2224-3151.206748  PMID:28612810
Background: The extended care model of the United Nations Children’s Fund (UNICEF) identifies knowledge/beliefs, nutritional status, mental health, control of resources/autonomy, workload/time constraints and social support as important caregiver resources for childcare. The aim of this paper is to examine the role of mothers’ caregiving resources in child-care practices in slums. Methods: A cross-sectional study was conducted in 10 slums of Hyderabad, to appraise the caregiving practices and health status of children under 5 years. Data were collected from 506 households, selected through multistage stratified random sampling, and data relating to 451 children aged 6–59 months were analysed. Four caregiving practices were studied: psychosocial stimulation, as assessed by the Home Observation Measurement of the Environment inventory; hygienic care rated by spot-check observation; and meal frequency and dietary diversity based on maternal recall. The role of the mother’s caregiving resources was examined using bivariate and multivariate logistic regression analyses. Results: More than 50% of the children received good psychosocial stimulation and close to 60% had good hygienic care. About 75% of the children aged 6–23 months had the recommended minimum meal frequency and 13% had the recommended dietary diversity. Mother’s media exposure (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.35–3.77), participation in household budgeting (OR 2.19, CI 1.25–3.83) and husband’s support (OR 2.04, CI 1.28–3.24) were predictors of psychosocial stimulation. Mother’s younger age (OR 1.11, CI 1.04–1.18), poor media exposure (OR 1.95, CI 1.15–3.29), dissatisfaction with life (OR 1.84, CI 1.05–3.24), workload (OR 1.79, CI 1–3.18) and having no money for their own use (OR 1.52, CI 0.95–2.45) placed children at higher odds for receiving poor hygienic care. Leisure time (OR 2.75, CI 1.25–6.06) and participation in budgeting (OR 1.97, CI 1–3.86) were predictors of meal frequency. Conclusion: Mother’s workload, poor media exposure, dissatisfaction with life, lack of husband’s support and absence of economic autonomy are constraints to good child care in slums.
  3 913 110
POLICY AND PRACTICE
Universal access to medicines: evidence from Rajasthan, India
Sakthivel Selvaraj, Indranil Mukhopadhyay, Preeti Kumar, Malini Aisola, Pritam Datta, Pallav Bhat, Aashna Mehta, Swati Srivastava, Chhaya Pachauli
July-December 2014, 3(3):289-299
DOI:10.4103/2224-3151.206752  PMID:28612814
India has outlined its commitment to achieving universal health coverage and several states in India are rolling out strategies to support this aim. In 2011, Rajasthan implemented an ambitious universal access to medicines programme based on a centralized procurement and decentralized distribution model. In terms of the three dimensions of universal health coverage, the scheme has made significant positive strides within a short period of implementation. The key objectives of this paper are to assess the likely implications of providing universal access to essential medicines in Rajasthan, which has a population of 70 million. Primary field-level data were obtained from 112 public health-care facilities using multistage random sampling. National Sample Survey Organization data and health system data were also analysed. The per capita health expenditure during the pre-reform period was estimated to be ₹5.7 and is now close to ₹50. Availability of essential medicines was encouraging and utilization of public facilities had increased. With additional per capita annual investment of ₹43, the scheme has brought about several improvements in the delivery of essential services and increased utilization of public facilities in the state and, as a result, enhanced efficiency of the system. Although there was an attempt to convert the scheme into a targeted one with the change in government, strong resistance from the civil society resulted in such efforts being defeated and the universality of the scheme has been retained.
  3 939 85
ORIGINAL RESEARCH
Measuring universal health coverage: a three-dimensional composite approach from Bhutan
Jayendra Sharma, Kado Zangpo, John Grundy
July-December 2014, 3(3):226-237
DOI:10.4103/2224-3151.206745  PMID:28612807
Background: In the early 1960s, the Kingdom of Bhutan began to develop its modern health-care system and by the 1990s had developed an extensive network of health-care facilities. These developments, in tandem with wider social and economic progress encapsulated in the Gross National Happiness concept, have resulted in major gains in child survival and life expectancy in the past 50 years. In order to sustain these gains, the country has identified a constitutional and health-policy mandate for universal access to health. Methods: Based on analysis of the literature, and qualitative and quantitative health data, this case study aims to provide an assessment of universal health coverage in Bhutan, and to identify the major challenges to measuring, monitoring and sustaining universal coverage. Results: The study reveals that the wide network of primary and secondary care, reinforced by constitutional and policy mandates, ensures high population coverage, as well as wide availability and accessibility of care, with significant levels of financial protection. This achievement has been attributable to sustained state investment in the sector over past decades. Despite this achievement, recent surveys have demonstrated gaps in utilization of health services and confirmed associations between socioeconomic variables and health access and outcomes, which raise important questions relating to both supply- and demand-side barriers in accessing health care. Conclusion: In order to sustain and improve the quality of universal health coverage, improved measurements of service availability at subnational levels and of the determinants of pockets of low service utilization are required. More rigorous monitoring of financial protection is also needed, particularly in relation to rates of public investment and the impact of out-of-pocket costs while accessing care. These approaches should assist improvements in quality and equity in universal health coverage, in the context of ongoing epidemiological, demographic and social transition.
  2 1,586 178
Correlates of out-of-pocket spending on health in Nepal: implications for policy
Indrani Gupta, Samik Chowdhury
July-December 2014, 3(3):238-246
DOI:10.4103/2224-3151.206746  PMID:28612808
Background: A key objective of universal health coverage is to address inequities in the financial implications of health care. This paper examines the level and trend in out-of-pocket spending (OOPS) on health, and the consequent burden on Nepalese households. Methods: Using data from the Nepal Living Standard Survey for 1995–1996 and 2010–2011, the paper looks at the inequity of this burden and its changes over time; across ecological zones or belts, development regions, places of residence, or consumption expenditure quintiles; and according to the gender of the head of the household. Results: The average per capita OOPS on health in Nepal increased sevenfold in nominal terms between 1995–1996 and 2010–2011. The share of OOPS in household consumption expenditure also increased during the same period, primarily as a result of higher health spending by poorer households. Thirteen per cent of all households were found to incur catastrophic health expenses in 2010–2011. This proportion of households incurring such expenditure rose between the two time periods most sharply in the Terai belt, eastern region and poorest quintile. Conclusion: The health-financing system in Nepal has become regressive over the years, as the share of the bottom two quintiles in the total number of households facing catastrophic burden increased by 14% between the two periods.
  2 1,125 162
POLICY AND PRACTICE
Evidence-informed policy formulation: the case of the voucher scheme for maternal and child health in Myanmar
Yot Teerawattananon, Sripen Tantivess, Pitsaphun Werayingyong, Pritaporn Kingkaew, Nilar Tin, San San Aye, Phone Myint
July-December 2014, 3(3):285-288
DOI:10.4103/2224-3151.206751  PMID:28612813
Introduction: In 2010, with financial support from the Global Alliance for Vaccine and Immunization’s Health System Strengthening programme, the Government of Myanmar established a scheme to improve coverage of maternal and child health (MCH) services. Employing qualitative approaches, this article reviews the processes through which this scheme was devised, focusing on evidence generation and the use of such evidence to inform policy formulation. To address the problem of high mortality rates among mothers and infants, collaborative research was conducted by Myanmar’s Ministry of Health, the World Health Organization, and a research arm of Thailand’s Ministry of Public Health, between March 2010 and September 2011. In the early phase of this study, key barriers to government-provided MCH services were identified. Based on a comprehensive review of the literature, the introduction of a voucher scheme was raised for consideration by ministry of health decision-makers and respective stakeholders. Despite the successful experience of this financing strategy in low-income countries, a series of surveys, an economic evaluation, and focus group discussions were carried out to assess the feasibility and potential health and economic implications of this scheme in the Myanmar context. The research findings were then used to guide the design and adoption of the newly established initiative.
  2 726 97
ORIGINAL RESEARCH
Access to and utilization of voucher scheme for referral transport: a qualitative study in a district of West Bengal, India
Dipta K Mukhopadhyay, Sujishnu Mukhopadhyay, Dilip K Das, Apurba Sinhababu, Kaninika Mitra, Akhil B Biswas
July-December 2014, 3(3):247-253
DOI:10.4103/2224-3151.206747  PMID:28612809
Background: Lack of motorized transport in remote areas and cash in resource-constrained settings are major obstacles to women accessing skilled care when giving birth. To address these issues, a cashless voucher transport scheme to enable women to give birth in a health-care institution, covering poor and marginalized women, was initiated by the National Rural Health Mission in selected districts of India in 2009. Methods: The access to and utilization of the voucher scheme were assessed between December 2010 and February 2011 through a qualitative study in the district of Purulia, West Bengal, India. Data were collected from in-depth interviews and focus group discussions with women, front-line health-care workers, programme managers and service providers. Results: The main factors influencing coverage and utilization of the scheme were: reliance on ill-prepared gram panchayats (village councils) for identification of eligible women; poor birth preparedness initiatives by health-care workers; over-reliance on telephone communication; restricted availability of vehicles, especially at night and in remote areas; no routine monitoring; drivers’ demand for extra money in certain situations; and low reimbursement for drivers for long-distance travel. Conclusion: Departure from guidelines, ritualistic implementation and little stress on preparedness of both the community and the health system were major obstacles. Increased enthusiasm among stakeholders and involvement of the community would provide opportunities for strengthening the scheme.
  1 589 53
PERSPECTIVE
Public financing to close gaps in universal health coverage in South-East Asia
Robert Yates
July-December 2014, 3(3):204-205
DOI:10.4103/2224-3151.206741  PMID:28612803
  1 525 44
POLICY AND PRACTICE
Health spending, macroeconomics and fiscal space in countries of the World Health Organization South-East Asia Region
Indrani Gupta, Swadhin Mondal
July-December 2014, 3(3):273-284
DOI:10.4103/2224-3151.206750  PMID:28612812
The paper examines the issues around mobilization of resources for the 11 countries of the South-East Asia Region of the World Health Organization (WHO), by analysing their macroeconomic situation, health spending, fiscal space and other determinants of health. With the exception of a few, most of these countries have made fair progress on their own Millennium Development Goal (MDG) targets of maternal mortality ratio and mortality rate in children aged under 5 years. However, the achieved targets have been very modest – with the exception of Thailand and Sri Lanka – indicating the continued need for additional efforts to improve these indicators. The paper discusses the need for investment, by looking at evidence on economic growth, the availability of fiscal space, and improvements in “macroeconomic-plus” factors like poverty, female literacy, governance and efficiency of the health sector. The analysis indicates that, overall, the countries of the WHO South-East Asia Region are collectively in a position to make the transition from low public spending to moderate or even high health spending, which is required, in turn, for transition from lowcoverage–high out-of-pocket spending (OOPS) to highcoverage–low OOPS. However, explicit prioritization for health within the overall government budget for low spenders would require political will and champions who can argue the case of the health sector. Additional innovative avenues of raising resources, such as earmarked taxes or a health levy can be considered in countries with good macroeconomic fundamentals. With the exception of Thailand, this is applicable for all the countries of the region. However, countries with adverse macroeconomic-plus factors, as well as inefficient health systems, need to be alert to the possibility of overinvesting – and thereby wasting – resources for modest health gains, making the challenge of increasing health sector spending alongside competing demands for spending on other areas of the social sector difficult.
  1 806 94
REVIEW
Reprioritizing government spending on health: pushing an elephant up the stairs?
Ajay Tandon, Lisa Fleisher, Rong Li, Wei Aun Yap
July-December 2014, 3(3):206-212
DOI:10.4103/2224-3151.206742  PMID:28612804
Countries vary widely with respect to the share of government spending on health, a metric that can serve as a proxy for the extent to which health is prioritized by governments. World Health Organization (WHO) data estimate that, in 2011, health’s share of aggregate government expenditure averaged 12% in the 170 countries for which data were available. However, country differences were striking: ranging from a low of 1% in Myanmar to a high of 28% in Costa Rica. Some of the observed differences in health’s share of government spending across countries are unsurprisingly related to differences in national income. However, significant variations exist in health’s share of government spending even after controlling for national income. This paper provides a global overview of health’s share of government spending and summarizes some of the key theoretical and empirical perspectives on allocation of public resources to health vis-à-vis other sectors from the perspective of reprioritization, one of the modalities for realizing fiscal space for health. The paper argues that theory and cross-country empirical analyses do not provide clear-cut explanations for the observed variations in government prioritization of health. Standard economic theory arguments that are often used to justify public financing for health are equally applicable to many other sectors including defence, education and infrastructure. To date, empirical work on prioritization has been sparse: available cross-country econometric analyses suggest that factors such as democratization, lower levels of corruption, ethnolinguistic homogeneity and more women in public office are correlated with higher shares of public spending on health; however, these findings are not robust and are sensitive to model specification. Evidence from case studies suggests that country-specific political economy considerations are key, and that results-focused reform efforts – in particular efforts to explicitly expand the breadth and depth of health coverage as opposed to efforts focused only on government budgetary benchmarking targets – are more likely to result in sustained and politically feasible prioritization of health from a fiscal space perspective.
  1 677 125
Universal health coverage reforms: implications for the distribution of the health workforce in low-and middle-income countriess
Barbara McPake, Ijeoma Edoka
July-December 2014, 3(3):213-218
DOI:10.4103/2224-3151.206743  PMID:28612805
To achieve universal health coverage (UHC), a range of health-financing reforms, including removal of user fees and the expansion of social health insurance, have been implemented in many countries. While the focus of much research and discussion on UHC has been on the impact of health-financing reforms on population coverage, health-service utilization and out-of-pocket payments, the implications of such reforms for the distribution and performance of the health workforce have often been overlooked. Shortages and geographical imbalances in the distribution of skilled health workers persist in many low- and middle-income countries, posing a threat to achieving UHC. This paper suggests that there are risks associated with health-financing reforms, for the geographical distribution and performance of the health workforce. These risks require greater attention if poor and rural populations are to benefit from expanded financial protection.
  1 790 124
EDITORIAL
Universal health coverage in South-East Asia: documenting the evidence for a Regional Strategy
Alaka Singh
July-December 2014, 3(3):197-198
DOI:10.4103/2224-3151.206738  PMID:28612800
  - 546 35
FOREWORD
Foreword
Poonam Khetrapal Singh
July-December 2014, 3(3):0-0
DOI:10.4103/2224-3151.206753  
  - 352 14
FROM THE LITERATURE
From The Lancet: East Timor striving for universal access to health care

July-December 2014, 3(3):200-201
PMID:28612801
  - 353 20
From the Results for Development (R4D) Institute: An Interview with Dr David Evans of the World Health Organization

July-December 2014, 3(3):202-203
PMID:28612802
  - 341 15
ORIGINAL RESEARCH
Strengthening public health laboratory capacity in Thailand for International Health Regulations (IHR) (2005)
Anne Harwood Peruski, Maureen Birmingham, Chawalit Tantinimitkul, Ladawan Chungsamanukool, Preecha Chungsamanukool, Ratigorn Guntapong, Chaiwat Pulsrikarn, Ladapan Saengklai, Krongkaew Supawat, Aree Thattiyaphong, Duangdao Wongsommart, Wattanapong Wootta, Abdoulaye Nikiema, Antoine Pierson, Leonard F Peruski, Xin Liu, Mark A Rayfield
July-December 2014, 3(3):266-272
DOI:10.4103/2224-3151.206749  PMID:28612811
Introduction: Thailand conducted a national laboratory assessment of core capacities related to the International Health Regulations (IHR) (2005), and thereby established a baseline to measure future progress. The assessment was limited to public laboratories found within the Thai Bureau of Quality and Safety of Food, National Institute of Health and regional medical science centres. Methods: The World Health Organization (WHO) laboratory assessment tool was adapted to Thailand through a participatory approach. This adapted version employed a specific scoring matrix and comprised 16 modules with a quantitative output. Two teams jointly performed the on-site assessments in December 2010 over a two-week period, in 17 public health laboratories in Thailand. The assessment focused on the capacity to identify and accurately detect pathogens mentioned in Annex 2 of the IHR (2005) in a timely manner, as well as other public health priority pathogens for Thailand. Results: Performance of quality management, budget and finance, data management and communications was considered strong (>90%); premises quality, specimen collection, biosafety, public health functions, supplies management and equipment availability were judged as very good (>70% but ≤90%); while microbiological capacity, staffing, training and supervision, and information technology needed improvement (>60% but ≤70%). Conclusions: This assessment is a major step in Thailand towards development of an optimized and standardized national laboratory network for the detection and reporting of infectious disease that would be compliant with IHR (2005). The participatory strategy employed to adapt an international tool to the Thai contex can also serve as a model for use by other countries in the Region. The participatory approach probably ensured better quality and ownership of the results, while providing critical information to help decision-makers determine where best to invest finite resources.
  - 574 47
REVIEW
The application of social impact bonds to universal health-care initiatives in South-East Asia
Michael Belinsky, Michael Eddy, Johannes Lohmann, Michael Georgea
July-December 2014, 3(3):219-225
DOI:10.4103/2224-3151.206744  PMID:28612806
Social impact bonds (SIBs) have the potential to improve the efficiency of government health-care spending in South-East Asia. In a SIB, governments sign a pay-for-performance contract with one or several providers of health-care services, and the providers borrow up-front capital from investors. Governments outside South-East Asia have started to experiment with SIBs in criminal justice, homelessness and health care. Governments of South-East Asia can advance the goal of universal health care by using SIBs to improve the efficiency of health-care service providers and by motivating providers to expand coverage. This paper describes SIBs and their potential application to health-care initiatives in the Region.
  - 798 96
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