Learning across the UK: a review of public health systems and policy approaches to early child development since political devolution.

BACKGROUND: Giving children the best start in life is critical for their future health and wellbeing. Political devolution in the UK provides a natural experiment to explore how public health systems contribute to children's early developmental outcomes across four countries. METHOD: A systematic literature review and input from a stakeholder group was used to develop a public health systems framework. This framework then informed analysis of public health policy approaches to early child development. RESULTS: A total of 118 studies met the inclusion criteria. All national policies championed a 'prevention approach' to early child development. Political factors shaped divergence, with variation in national conceptualizations of child development ('preparing for life' versus 'preparing for school') and pre-school provision ('universal entitlement' or 'earned benefit'). Poverty and resourcing were identified as key system factors that influenced outcomes. Scotland and Wales have enacted distinctive legislation focusing on wider determinants. However, this is limited by the extent of devolved powers. CONCLUSION: The systems framework clarifies policy complexity relating to early child development. The divergence of child development policies in the four countries and, particularly, the explicit recognition in Scottish and Welsh policy of wider determinants, creates scope for this topic to be a tracer area to compare UK public health systems longer term.

Visualizing value for money in public health interventions.

Background: The Socio-Technical Allocation of Resources (STAR) has been developed for value for money analysis of health services through stakeholder workshops. This article reports on its application for prioritization of interventions within public health programmes. Methods: The STAR tool was used by identifying costs and service activity for interventions within commissioned public health programmes, with benefits estimated from the literature on economic evaluations in terms of costs per Quality-Adjusted Life Years (QALYs); consensus on how these QALY values applied to local services was obtained with local commissioners. Results: Local cost-effectiveness estimates could be made for some interventions. Methodological issues arose from gaps in the evidence base for other interventions, inability to closely match some performance monitoring data with interventions, and disparate time horizons of published QALY data. Practical adjustment for these issues included using population prevalences and utility states where intervention specific evidence was lacking, and subdivision of large contracts into specific intervention costs using staffing ratios. The STAR approach proved useful in informing commissioning decisions and understanding the relative value of local public health interventions. Conclusions: Further work is needed to improve robustness of the process and develop a visualization tool for use by public health departments.

Referral to hospital in Nepal: 4 years' experience in one rural district.

Formal referral systems have been proposed as a strategy to improve access to secondary care, yet their implementation can be problematic. This paper describes data from referrals in one rural district in Nepal over a 4-year period. Whilst the characteristics of those patients attending hospital after referral were similar to those described in other developing countries, the rate (1.0/1000 population/year) is much lower, especially when compared to estimated need. Geographical and other barriers to access to secondary care in rural Nepal are discussed.

Study on urinary bladder stone cases at Okhaldhunga Hospital, Nepal. 1988--1994.

A retrospective study on urinary bladder stones among the patients seeking treatment in Okhaldunga Hospital was carried out for six calendar years from 1988 to 1994. Forty-six cases of bladder stones were identified during that period. Among them, 43 patients' records were studied (93.0%) in subsequent analysis. Ninety-seven percent were male with mean age 11.53+/-6.9 years. The number of children are significantly higher in 0-9 years of age (p<0.01). The symptoms lasted more than 2 years with the most common presenting symptoms dysuria (86.0%) and poor flow of urine (41.8%). The average hospital stay was 8.7 days. The majority of cases (78.5%) had undergone cystolithotomy without any complications. The study also showed that the majority (97.0%) of urinary bladder stone cases were successfully managed at a rural hospital like Okhaldhunga.

A systematic review of current knowledge of HIV epidemiology and of sexual behaviour in Nepal.

OBJECTIVE: To systematically review information on HIV epidemiology and on sexual behaviour in Nepal with a view to identifying gaps in current knowledge. METHODS: Systematic review covering electronic databases, web-based information, personal contact with experts and hand searching of key journals. RESULTS: HIV-1 seroprevalence has been rising rapidly in association with high-risk behaviours, with current levels of 40% amongst the nation's injecting drug users and approaching 20% amongst Kathmandu's female commercial sex workers (FCSWs). HIV seroprevalence remains low in the general population (0.29% of 15-49 year olds). There are significant methodological limitations in many of the seroprevalence studies identified, and these estimates need to be treated with caution. There are extensive migration patterns both within the country and internationally which provide the potential for considerable sexual networking. However, studies of sexual behaviour have focused on FCSWs and the extent of sexual networks within the general population is largely unknown. CONCLUSIONS: Whilst some of the ingredients are present for an explosive HIV epidemic in Nepal, crucial knowledge on sexual behaviour in the general population is missing. Research on sexual networking is urgently required to guide HIV control in Nepal. There is also a need for further good-quality epidemiological studies of HIV seroprevalence.