Geographic barriers to establishing a successful hospital referral system in rural Madagascar

BackgroundThe provision of emergency and hospital care has become an integral part of the global vision for universal health coverage. To strengthen secondary care systems, we need to accurately understand the time necessary for populations to reach a hospital. The goal of this study was to develop methods that accurately estimate referral and prehospital time for rural districts in low and middle-income countries. We used these estimates to assess how local geography can limit the impact of a strengthened referral programme in a rural district of Madagascar.MethodsWe developed a database containing: travel speed by foot and motorised vehicles in Ifanadiana district; a full mapping of all roads, footpaths and households; and remotely sensed data on terrain, land cover and climatic characteristics. We used this information to calibrate estimates of referral and prehospital time based on the shortest route algorithms and statistical models of local travel speed. We predict the impact on referral numbers of strategies aimed at reducing referral time for underserved populations via generalised linear mixed models.ResultsAbout 10% of the population lived less than 2 hours from the hospital, and more than half lived over 4 hours away, with variable access depending on climatic conditions. Only the four health centres located near the paved road had referral times to the hospital within 1 hour. Referral time remained the main barrier limiting the number of referrals despite health system strengthening efforts. The addition of two new referral centres is estimated to triple the population living within 2 hours from a centre with better emergency care capacity and nearly double the number of expected referrals.ConclusionThis study demonstrates how adapting geographic accessibility modelling methods to local scales can occur through improving the precision of travel time estimates and pairing them with data on health facility use.

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Geographic barriers to establishing a successful hospital referral system in rural Madagascar

10.1101/2021.08.06.21261682 ◽

2021 ◽

Author(s):

Felana Angella Ihantamalala ◽

Matthew H. Bonds ◽

Mauricianot Randriamihaja ◽

Luc Rakotonirina ◽

Vincent Herbreteau ◽

...

Keyword(s):

Health System ◽

Universal Health Coverage ◽

Travel Speed ◽

Health System Strengthening ◽

Local Health ◽

Health Coverage ◽

Geographic Accessibility ◽

Hospital Referral ◽

The Impact ◽

Universal Health

Background: The provision of emergency and hospital care has become an integral part of the global vision for universal health coverage. It is recommended that at least 80% of a country s population should be within two hours of a facility with essential surgery and anesthetic services. In order to strengthen health systems to achieve this goal, there needs to be an understanding of the time necessary for populations to reach a hospital. The goal of this study was to develop methods that accurately estimate referral and pre-hospital time for rural health districts in LMICs. We used these estimates to assess how the local geography can limit the impact of a strengthened referral program in a rural district of Madagascar. Methods: We developed a database containing 1) travel speed in a subset of routes by foot and motorized vehicles in Ifanadiana District; 2) a full mapping of all roads, footpaths and households in the district; and 3) remotely sensed data on terrain, land cover and climatic characteristics. We used this information to calibrate estimates of referral and pre-hospital time based on shortest route algorithms and statistical models of local travel speed. We compared these estimates with those from other commonly used methods in geographic accessibility modeling. Finally, we studied the impact of referral time on the evolution of the number of referrals completed by each health center in the district in 2014-2020 via generalized linear mixed models, using model estimates to predict the impact on referral numbers of strategies aimed at reducing referral time for underserved populations. Results: About 10% of the population lived less than two hours from the hospital, and more than half lived over four hours away, with variable access depending on climatic conditions. Only the four health centers (out of 21) located near the paved road had referral times to the hospital within one hour, which contributed over 75% of all 8,464 hospital referrals. Referral time remained the main barrier limiting the number of referrals despite health system strengthening efforts. The addition of two new referral centers is estimated to triple the population living within two hours from a center with higher acute care capacity and nearly double the number of referrals expected. Conclusion: This study demonstrates how adapting geographic accessibility modeling methods to local scales can occur through improving the precision of travel time estimates and pairing them with data on health facility data. Such information can substantially improve the design of a local health system to overcome existing barriers to care and achieve universal health coverage.

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Evaluating medical education regulation changes in Brazil: workforce impact

Human Resources for Health ◽

10.1186/s12960-021-00580-5 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Alexandre Medeiros Figueiredo ◽

Danette Waller McKinley ◽

Adriano Massuda ◽

George Dantas Azevedo

Keyword(s):

Medical Education ◽

Public Schools ◽

Low Income ◽

School Enrollment ◽

Health Coverage ◽

Continuous Assessment ◽

Middle Income ◽

Unified Health System ◽

Medical Undergraduate ◽

The Impact

Abstract Background Shortages and inequitable distribution of physicians is an obstacle to move towards Universal Health Coverage, especially in low-income and middle-income countries. In Brazil, expansion of medical school enrollment, curricula changes and recruitment programs were established to increase the number of physicians in underserved areas. This study seeks to analyze the impact of these measures in reduce inequities in access to medical education and physicians’ distribution. Methods This is an observational study that analyzes changes in the number of undergraduate medical places and number of physicians per inhabitants in different areas in Brazil between the years 2010 and 2018. Data regarding the number of undergraduate medical places, number and the practice location of physicians were obtained in public databases. Municipalities with less than 20,000 inhabitants were considered underserved areas. Data regarding access to antenatal visits were analyzed as a proxy for impact in access to healthcare. Results From 2010 to 2018, 19,519 new medical undergraduate places were created which represents an increase of 120.2%. The increase in the number of physicians engaged in the workforce throughout the period was 113,702 physicians, 74,771 of these physicians in the Unified Health System. The greatest increase in the physicians per 1000 inhabitants ratio in the municipalities with the smallest population, the lowest Gross Domestic Product per capita and in those located in the states with the lowest concentration of physicians occurred in the 2013–2015 period. Increase in physician supply improved access to antenatal care. Conclusions There was an expansion in the number of undergraduate medical places and medical workforce in all groups of municipalities assessed in Brazil. Medical undergraduate places expansion in the federal public schools was more efficient to reduce regional inequities in access to medical education than private sector expansion. The recruitment component of More Doctors for Brazil Program demonstrated effectiveness to increase the number of physicians in underserved areas. Our results indicate the importance of public policies to face inequities in access to medical education and physician shortages and the necessity of continuous assessment during the period of implementation, especially in the context of political and economic changes.

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The impact of pulse oximetry on diagnosis, management and outcomes of acute febrile illness in low-income and middle-income countries: a systematic review

BMJ Global Health ◽

10.1136/bmjgh-2021-007282 ◽

2021 ◽

Vol 6 (11) ◽

pp. e007282

Author(s):

Rusheng Chew ◽

Meiwen Zhang ◽

Arjun Chandna ◽

Yoel Lubell

Keyword(s):

Pulse Oximetry ◽

Patient Outcomes ◽

Febrile Illness ◽

Risk Of Bias ◽

Acute Febrile Illness ◽

Middle Income ◽

Middle Income Countries ◽

Low Middle Income Countries ◽

Hospital Referral ◽

The Impact

BackgroundAcute fever is a common presenting symptom in low/middle-income countries (LMICs) and is strongly associated with sepsis. Hypoxaemia predicts disease severity in such patients but is poorly detected by clinical examination. Therefore, including pulse oximetry in the assessment of acutely febrile patients may improve clinical outcomes in LMIC settings.MethodsWe systematically reviewed studies of any design comparing one group where pulse oximetry was used and at least one group where it was not. The target population was patients of any age presenting with acute febrile illness or associated syndromes in LMICs. Studies were obtained from searching PubMed, EMBASE, CABI Global Health, Global Index Medicus, CINAHL, Cochrane CENTRAL, Web of Science and DARE. Further studies were identified through searches of non-governmental organisation websites, snowballing and input from a Technical Advisory Panel. Outcomes of interest were diagnosis, management and patient outcomes. Study quality was assessed using the Cochrane Risk of Bias 2 tool for Cluster Randomised Trials and Risk of Bias in Non-randomized Studies of Interventions tools, as appropriate.ResultsTen of 4898 studies were eligible for inclusion. Their small number and heterogeneity prevented formal meta-analysis. All studies were in children, eight only recruited patients with pneumonia, and nine were conducted in Africa or Australasia. Six were at serious risk of bias. There was moderately strong evidence for the utility of pulse oximetry in diagnosing pneumonia and identifying severe disease requiring hospital referral. Pulse oximetry used as part of a quality-assured facility-wide package of interventions may reduce pneumonia mortality, but studies assessing this endpoint were at serious risk of bias.ConclusionsVery few studies addressed this important question. In LMICs, pulse oximetry may assist clinicians in diagnosing and managing paediatric pneumonia, but for the greatest impact on patient outcomes should be implemented as part of a health systems approach. The evidence for these conclusions is not widely generalisable and is of poor quality.

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The Impact of Conflict on Immunisation Coverage in 16 Countries

International Journal of Health Policy and Management ◽

10.15171/ijhpm.2018.127 ◽

2018 ◽

Vol 8 (4) ◽

pp. 211-221 ◽

Cited By ~ 6

Author(s):

John Grundy ◽

Beverley-Ann Biggs

Keyword(s):

Health System ◽

Disease Incidence ◽

National Policy ◽

Disease Outbreaks ◽

Health System Strengthening ◽

World Health ◽

Immunisation Coverage ◽

Global Alliance ◽

Middle Income ◽

The Impact

Background: Military conflict has been an ongoing determinant of inequitable immunisation coverage in many low- and middle-income countries, yet the impact of conflict on the attainment of global health goals has not been fully addressed. This review will describe and analyse the association between conflict, immunisation coverage and vaccine-preventable disease (VPD) outbreaks, along with country specific strategies to mitigate the impact in 16 countries. Methods: We cross-matched immunisation coverage and VPD data in 2014 for displaced and refugee populations. Data on refugee or displaced persons was sourced from the United Nations High Commissioner for Refugees (UNHCR) database, and immunisation coverage and disease incidence data from World Health Organization (WHO) databases. Demographic and Health Survey (DHS) databases provided additional data on national and sub-national coverage. The 16 countries were selected because they had the largest numbers of registered UNHCR "persons of interest" and received new vaccine support from Global Alliance for Vaccine and Immunisation (GAVI), the Vaccine Alliance. We used national planning and reporting documentation including immunisation multiyear plans, health system strengthening strategies and GAVI annual progress reports (APRs) to assess the impact of conflict on immunisation access and coverage rates, and reviewed strategies developed to address immunisation program shortfalls in conflict settings. We also searched the peer-reviewed literature for evidence that linked immunisation coverage and VPD outbreaks with evidence of conflict. Results: We found that these 16 countries, representing just 12% of the global population, were responsible for 67% of global polio cases and 39% of global measles cases between 2010 and 2015. Fourteen out of the 16 countries were below the global average of 85% coverage for diphtheria, pertussis, and tetanus (DPT3) in 2014. We present data from countries where the onset of conflict has been associated with sudden drops in national and sub-national immunisation coverage. Tense security conditions, along with damaged health infrastructure and depleted human resources have contributed to infrequent outreach services, and delays in new vaccine introductions and immunisation campaigns. These factors have in turn contributed to pockets of low coverage and disease outbreaks in sub-national areas affected by conflict. Despite these impacts, there was limited reference to the health needs of conflict affected populations in immunisation planning and reporting documents in all 16 countries. Development partner investments were heavily skewed towards vaccine provision and working with partner governments, with comparatively low levels of health systems support or civil partnerships. Conclusion: Global and national policy and planning focus is required on the service delivery needs of conflict affected populations, with increased investment in health system support and civil partnerships, if persistent immunisation inequities in conflict affected areas are to be addressed.

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Public health priorities in countries undergoing economic transition

10.1093/med/9780198816805.003.0004 ◽

2021 ◽

pp. 47-62

Author(s):

Stephen Tollman ◽

Jessica Price

Keyword(s):

Economic Transition ◽

Health Priorities ◽

Intersectoral Collaboration ◽

Health Coverage ◽

Middle Income ◽

Demographic Transitions ◽

Middle Income Countries ◽

Impact Of Urbanization ◽

The Life Course ◽

The Impact

This chapter starts by reviewing the relationship between the economy and health, looking at changes in health outcome as income increases, demographic transitions related to economic growth, and the impact of urbanization on health outcomes. It then reviews major health challenges facing middle-income countries (MICs), including the triple burden of disease, multimorbidity, mental health across the life course, and the impacts of migration, climate change, and antimicrobial resistance. Finally, it discusses health system challenges and the importance of building resilient and ‘learning’ health systems with the agility to adapt to meet MICs’ evolving health needs. We discuss strategies to achieve universal health coverage in MICs and the importance of intersectoral collaboration in promoting health.

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Globalization of national surgical, obstetric and anesthesia plans: the critical link between health policy and action in global surgery

Globalization and Health ◽

10.1186/s12992-019-0531-5 ◽

2020 ◽

Vol 16 (1) ◽

Cited By ~ 11

Author(s):

Paul Truché ◽

Haitham Shoman ◽

Ché L. Reddy ◽

Desmond T. Jumbam ◽

Joanna Ashby ◽

...

Keyword(s):

Financial Burden ◽

Surgical Care ◽

Obstetric Care ◽

Global Surgery ◽

Health System Strengthening ◽

Health Coverage ◽

Middle Income ◽

Middle Income Countries ◽

Private And Public ◽

Development Goals

AbstractEfforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners – individuals and institutions – help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.

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Distributional impact of the Malawian Essential Health Package

Health Policy and Planning ◽

10.1093/heapol/czaa015 ◽

2020 ◽

Vol 35 (6) ◽

pp. 646-656

Author(s):

Matthias Arnold ◽

Dominic Nkhoma ◽

Susan Griffin

Keyword(s):

Population Health ◽

Health Inequality ◽

Census Data ◽

Health Benefits ◽

Health Gain ◽

Health Coverage ◽

Potential Health ◽

Middle Income ◽

The Impact ◽

Benefits Package

Abstract In low- and middle-income countries (LMICs), making the best use of scarce resources is essential to achieving universal health coverage. The design of health benefits packages creates the opportunity to select interventions on the basis of explicit objectives. Distributional cost-effectiveness analysis (DCEA) provides a framework to evaluate interventions based on two objectives: increasing population health and reducing health inequality. We conduct aggregate DCEA of potential health benefits package interventions to demonstrate the feasibility of this approach in LMICs, using the case of the Malawian health benefits package. We use publicly available survey and census data common to LMICs and describe what challenges we encountered and how we addressed them. We estimate that diseases targeted by the health benefits package are most prevalent in the poorest population quintile and least prevalent in the richest quintile. The survey data we use indicate socioeconomic patterns in intervention uptake that diminish the population health gain and inequality reduction from the package. We find that a similar set of interventions would be prioritized when impact on health inequality is incorporated alongside impact on overall population health. However, conclusions about the impact of individual interventions on health inequalities are sensitive to assumptions regarding the health opportunity cost, the utilization of interventions, the distribution of diseases across population groups and the level of aversion to inequality. Our results suggest that efforts to improve access to the Essential Health Package could be targeted to specific interventions to improve the health of the poorest fastest but that identifying these interventions is uncertain. This exploratory work has shown the potential for applying the DCEA framework to inform health benefits package design within the LMIC setting and to provide insight into the equity impact of a health benefits package.

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Impact of roof shading on building energy performance in warm & humid climatic places of India

iCRBE Procedia ◽

10.32438/icrbe.202037 ◽

2020 ◽

pp. 50-64

Author(s):

Kuladeep Kumar Sadevi ◽

Avlokita Agrawal

Keyword(s):

Energy Consumption ◽

Energy Conservation ◽

Energy Performance ◽

General Assumption ◽

Climatic Conditions ◽

Building Envelope ◽

Passive Cooling ◽

Base Case ◽

U Value ◽

The Impact

With the rise in awareness of energy efficient buildings and adoption of mandatory energy conservation codes across the globe, significant change is being observed in the way the buildings are designed. With the launch of Energy Conservation Building Code (ECBC) in India, climate responsive designs and passive cooling techniques are being explored increasingly in building designs. Of all the building envelope components, roof surface has been identified as the most significant with respect to the heat gain due to the incident solar radiation on buildings, especially in tropical climatic conditions. Since ECBC specifies stringent U-Values for roof assembly, use of insulating materials is becoming popular. Along with insulation, the shading of the roof is also observed to be an important strategy for improving thermal performance of the building, especially in Warm and humid climatic conditions. This study intends to assess the impact of roof shading on building’s energy performance in comparison to that of exposed roof with insulation. A typical office building with specific geometry and schedules has been identified as base case model for this study. This building is simulated using energy modelling software ‘Design Builder’ with base case parameters as prescribed in ECBC. Further, the same building has been simulated parametrically adjusting the amount of roof insulation and roof shading simultaneously. The overall energy consumption and the envelope performance of the top floor are extracted for analysis. The results indicate that the roof shading is an effective passive cooling strategy for both naturally ventilated and air conditioned buildings in Warm and humid climates of India. It is also observed that a fully shaded roof outperforms the insulated roof as per ECBC prescription. Provision of shading over roof reduces the annual energy consumption of building in case of both insulated and uninsulated roofs. However, the impact is higher for uninsulated roofs (U-Value of 3.933 W/m2K), being 4.18% as compared to 0.59% for insulated roofs (U-Value of 0.33 W/m2K).While the general assumption is that roof insulation helps in reducing the energy consumption in tropical buildings, it is observed to be the other way when insulation is provided with roof shading. It is due to restricted heat loss during night.

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The Impact of Covid 19 on Pregnant Women and Child Health

International Journal of Research in Pharmaceutical Sciences ◽

10.26452/ijrps.v11ispl1.3645 ◽

2020 ◽

Vol 11 (SPL1) ◽

pp. 1367-1373

Author(s):

Nikhil Sanjay Mujbaile ◽

Smita Damke

Keyword(s):

Social Issues ◽

Middle Income ◽

Web Based ◽

Middle Income Countries ◽

Low Middle Income Countries ◽

The Social ◽

Social Separation ◽

The Impact ◽

And Child Health ◽

General Wellbeing

The Covid illness (COVID-19) pandemic has spread rapidly all through the world and has had a drawn-out impact. The Pandemic has done incredible damage to society and made genuine mental injury to numerous individuals. Mental emergencies frequently cause youngsters to deliver sentiments of relinquishment, despondency, insufficiency, and fatigue and even raise the danger of self-destruction. Youngsters with psychological instabilities are particularly powerless during the isolate and colonial removing period. Convenient and proper assurances are expected to forestall the event of mental and social issues. The rising advanced applications and wellbeing administrations, for example, telehealth, web-based media, versatile wellbeing, and far off intuitive online instruction can connect the social separation and backing mental and conduct wellbeing for youngsters. Because of the mental advancement qualities of youngsters, this investigation additionally outlines intercessions on the mental effect of the COVID-19 Pandemic. Further difficulties in Low Middle-Income Countries incorporate the failure to actualize successful general wellbeing estimates, for example, social separating, hand cleanliness, definitive distinguishing proof of contaminated individuals with self-disconnection and widespread utilization of covers The aberrant impacts of the Pandemic on youngster wellbeing are of extensive concern, including expanding neediness levels, upset tutoring, absence of admittance to the class taking care of plans, decreased admittance to wellbeing offices and breaks in inoculation and other kid wellbeing programs. Kept tutoring is critical for kids in Low Middle-Income Countries. Arrangement of safe situations is mainly testing in packed asset obliged schools.

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Doctor Retention in Ireland - What it may mean for the Global Health Workforce Reform Agenda Comment on "Doctor Retention: A Cross-sectional Study of How Ireland Has Been Losing the Battle"

International Journal of Health Policy and Management ◽

10.34172/ijhpm.2020.126 ◽

2020 ◽

Author(s):

Bernard Hope Taderera

Keyword(s):

Global Health ◽

Health Workforce ◽

Cross Sectional Study ◽

Early Career ◽

Healthcare Personnel ◽

Health Coverage ◽

Cross Sectional ◽

Middle Income ◽

Reform Agenda ◽

Medical Graduates

The study of healthcare personnel migration in Ireland reports that most medical graduates plan to leave the country’s health system. It may be possible to address this challenge by understanding and addressing the reasons why young doctors plan to leave. Future studies should contribute to the retention of early career doctors in highincome countries such as Ireland. This will help reduce the migration of doctors from low- and middle-income countries in order to address the global health workforce crisis and its impact on the attainment of universal health coverage in all health systems.

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