A method for measuring spatial effects on socioeconomic inequalities using the concentration index.

BACKGROUND: Although spatial effects contribute to inequalities in health care service utilisation and other health outcomes in low and middle income countries, there have been no attempts to incorporate the impact of neighbourhood effects into equity analyses based on concentration indices. This study aimed to decompose and estimate the contribution of spatial effects on inequalities in uptake of HIV tests in Malawi. METHODS: We developed a new method of reflecting spatial effects within the concentration index using a spatial weight matrix. Spatial autocorrelation is presented using a spatial lag model. We use data from the Malawi Demographic Health Survey (n = 24,562) to illustrate the new methodology. Need variables such as 'Any STI last 12 month', 'Genital sore/ulcer', 'Genital discharge' and non need variables such as Education, Literacy, Wealth, Marriage, and education were used in the concentration index. Using our modified concentration index that incorporates spatial effects, we estimate inequalities in uptake of HIV testing amongst both women and men living in Malawi in 2015-2016, controlling for need and non-need variables. RESULTS: For women, inequalities due to need variables were estimated at - 0.001 and - 0.0009 (pro-poor) using the probit and new spatial probit estimators, respectively, whereas inequalities due to non-need variables were estimated at 0.01 and 0.0068 (pro-rich) using the probit and new spatial probit estimators. The results suggest that spatial effects increase estimated inequalities in HIV uptake amongst women. Horizontal inequity was almost identical (0.0103 vs 0.0102) after applying the spatial lag model. For men, inequalities due to need variables were estimated at - 0.0002 using both the probit and new spatial probit estimators; however, inequalities due to non-need variables were estimated at - 0.006 and - 0.0074 for the probit and new spatial probit models. Horizontal inequity was the same for both models (- 0.0057). CONCLUSION: Our findings suggest that men from lower socioeconomic groups are more likely to receive an HIV test after adjustment for spatial effects. This study develops a novel methodological approach that incorporates estimation of spatial effects into a common approach to equity analysis. We find that a significant component of inequalities in HIV uptake in Malawi driven by non-need factors can be explained by spatial effects. When the spatial model was applied, the inequality due to non need in Lilongwe for men and horizontal inequity in Salima for women changed the sign. This approach can be used to explore inequalities in other contexts and settings to better understand the impact of spatial effects on health service use or other health outcomes, impacting on recommendations for service delivery.

Intervention strategies to improve nutrition and health behaviours before conception.

The nutritional status of both women and men before conception has profound implications for the growth, development, and long-term health of their offspring. Evidence of the effectiveness of preconception interventions for improving outcomes for mothers and babies is scarce. However, given the large potential health return, and relatively low costs and risk of harm, research into potential interventions is warranted. We identified three promising strategies for intervention that are likely to be scalable and have positive effects on a range of health outcomes: supplementation and fortification; cash transfers and incentives; and behaviour change interventions. On the basis of these strategies, we suggest a model specifying pathways to effect. Pathways are incorporated into a life-course framework using individual motivation and receptiveness at different preconception action phases, to guide design and targeting of preconception interventions. Interventions for individuals not planning immediate pregnancy take advantage of settings and implementation platforms outside the maternal and child health arena, since this group is unlikely to be engaged with maternal health services. Interventions to improve women's nutritional status and health behaviours at all preconception action phases should consider social and environmental determinants, to avoid exacerbating health and gender inequalities, and be underpinned by a social movement that touches the whole population. We propose a dual strategy that targets specific groups actively planning a pregnancy, while improving the health of the population more broadly. Modern marketing techniques could be used to promote a social movement based on an emotional and symbolic connection between improved preconception maternal health and nutrition, and offspring health. We suggest that speedy and scalable benefits to public health might be achieved through strategic engagement with the private sector. Political theory supports the development of an advocacy coalition of groups interested in preconception health, to harness the political will and leadership necessary to turn high-level policy into effective coordinated action.

Do Participatory Learning and Action Women's Groups Alone or Combined with Cash or Food Transfers Expand Women's Agency in Rural Nepal?

Participatory learning and action women's groups (PLA) have proven effective in reducing neonatal mortality in rural, high-mortality settings, but their impacts on women's agency in the household remain unknown. Cash transfer programmes have also long targeted female beneficiaries in the belief that this empowers women. Drawing on data from 1309 pregnant women in a four-arm cluster-randomised controlled trial in Nepal, we found little evidence for an impact of PLA alone or combined with unconditional food or cash transfers on women's agency in the household. Caution is advised before assuming PLA women's groups alone or with resource transfers necessarily empower women.

A cash-based intervention and the risk of acute malnutrition in children aged 6-59 months living in internally displaced persons camps in Mogadishu, Somalia: A non-randomised cluster trial.

BACKGROUND: Somalia has been affected by conflict since 1991, with children aged <5 years presenting a high acute malnutrition prevalence. Cash-based interventions (CBIs) have been used in this context since 2011, despite sparse evidence of their nutritional impact. We aimed to understand whether a CBI would reduce acute malnutrition and its risk factors. METHODS AND FINDINGS: We implemented a non-randomised cluster trial in internally displaced person (IDP) camps, located in peri-urban Mogadishu, Somalia. Within 10 IDP camps (henceforth clusters) selected using a humanitarian vulnerability assessment, all households were targeted for the CBI. Ten additional clusters located adjacent to the intervention clusters were selected as controls. The CBI comprised a monthly unconditional cash transfer of US$84.00 for 5 months, a once-only distribution of a non-food-items kit, and the provision of piped water free of charge. The cash transfers started in May 2016. Cash recipients were female household representatives. In March and September 2016, from a cohort of randomly selected households in the intervention (n = 111) and control (n = 117) arms (household cohort), we collected household and individual level data from children aged 6-59 months (155 in the intervention and 177 in the control arms) and their mothers/primary carers, to measure known malnutrition risk factors. In addition, between June and November 2016, data to assess acute malnutrition incidence were collected monthly from a cohort of children aged 6-59 months, exhaustively sampled from the intervention (n = 759) and control (n = 1,379) arms (child cohort). Primary outcomes were the mean Child Dietary Diversity Score in the household cohort and the incidence of first episode of acute malnutrition in the child cohort, defined by a mid-upper arm circumference < 12.5 cm and/or oedema. Analyses were by intention-to-treat. For the household cohort we assessed differences-in-differences, for the child cohort we used Cox proportional hazards ratios. In the household cohort, the CBI appeared to increase the Child Dietary Diversity Score by 0.53 (95% CI 0.01; 1.05). In the child cohort, the acute malnutrition incidence rate (cases/100 child-months) was 0.77 (95% CI 0.70; 1.21) and 0.92 (95% CI 0.53; 1.14) in intervention and control arms, respectively. The CBI did not appear to reduce the risk of acute malnutrition: unadjusted hazard ratio 0.83 (95% CI 0.48; 1.42) and hazard ratio adjusted for age and sex 0.94 (95% CI 0.51; 1.74). The CBI appeared to increase the monthly household expenditure by US$29.60 (95% CI 3.51; 55.68), increase the household Food Consumption Score by 14.8 (95% CI 4.83; 24.8), and decrease the Reduced Coping Strategies Index by 11.6 (95% CI 17.5; 5.96). The study limitations were as follows: the study was not randomised, insecurity in the field limited the household cohort sample size and collection of other anthropometric measurements in the child cohort, the humanitarian vulnerability assessment data used to allocate the intervention were not available for analysis, food market data were not available to aid results interpretation, and the malnutrition incidence observed was lower than expected. CONCLUSIONS: The CBI appeared to improve beneficiaries' wealth and food security but did not appear to reduce acute malnutrition risk in IDP camp children. Further studies are needed to assess whether changing this intervention, e.g., including specific nutritious foods or social and behaviour change communication, would improve its nutritional impact. TRIAL REGISTRATION: ISRCTN Registy ISRCTN29521514.

Optima Nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions.

BACKGROUND: Child stunting due to chronic malnutrition is a major problem in low- and middle-income countries due, in part, to inadequate nutrition-related practices and insufficient access to services. Limited budgets for nutritional interventions mean that available resources must be targeted in the most cost-effective manner to have the greatest impact. Quantitative tools can help guide budget allocation decisions. METHODS: The Optima approach is an established framework to conduct resource allocation optimization analyses. We applied this approach to develop a new tool, 'Optima Nutrition', for conducting allocative efficiency analyses that address childhood stunting. At the core of the Optima approach is an epidemiological model for assessing the burden of disease; we use an adapted version of the Lives Saved Tool (LiST). Six nutritional interventions have been included in the first release of the tool: antenatal micronutrient supplementation, balanced energy-protein supplementation, exclusive breastfeeding promotion, promotion of improved infant and young child feeding (IYCF) practices, public provision of complementary foods, and vitamin A supplementation. To demonstrate the use of this tool, we applied it to evaluate the optimal allocation of resources in 7 districts in Bangladesh, using both publicly available data (such as through DHS) and data from a complementary costing study. RESULTS: Optima Nutrition can be used to estimate how to target resources to improve nutrition outcomes. Specifically, for the Bangladesh example, despite only limited nutrition-related funding available (an estimated $0.75 per person in need per year), even without any extra resources, better targeting of investments in nutrition programming could increase the cumulative number of children living without stunting by 1.3 million (an extra 5%) by 2030 compared to the current resource allocation. To minimize stunting, priority interventions should include promotion of improved IYCF practices as well as vitamin A supplementation. Once these programs are adequately funded, the public provision of complementary foods should be funded as the next priority. Programmatic efforts should give greatest emphasis to the regions of Dhaka and Chittagong, which have the greatest number of stunted children. CONCLUSIONS: A resource optimization tool can provide important guidance for targeting nutrition investments to achieve greater impact.

Correction to: Optima nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions.

It has been highlighted that the original manuscript [1] contains a typesetting error in the name of Meera Shekar. This had been incorrectly captured as Meera Shekhar in the original article which has since been updated.

Revisiting the patriarchal bargain: The intergenerational power dynamics of household money management in rural Nepal.

Although power struggles between daughters-in-law and mothers-in-law in the South Asian household remain an enduring theme of feminist scholarship, current policy discourse on 'women's economic empowerment' in the Global South tends to focus on married women's power over their husband; this neglects intergenerational power dynamics. The aim of this study was to describe and analyze the processes involved in young, married women's negotiations of control over cash inside the extended household in a contemporary rural Nepali setting. We conducted a grounded theory study of 42 households from the Plains of Nepal. Our study uncovered multiple ways in which junior wives and husbands in the extended household became secret allies in seeking financial autonomy from the rule of the mother-in-law to the wife. This included secretly saving up for a household separation from the in-laws. We argue these secret financial strategies constitute a means for junior couples to renegotiate the terms of Kandiyoti's (1988) 'patriarchal bargain' wherein junior wives traditionally had to accept subservience to their husband and mother-in-law in exchange for economic security and eventual authority over their own daughters-in-law. Researchers, activists and policy-makers concerned with women's economic empowerment in comparable contexts should consider the impact of intergenerational power relations on women's control over cash.

Findings from a cluster randomised trial of unconditional cash transfers in Niger.

Unconditional cash transfers (UCTs) are used as a humanitarian intervention to prevent acute malnutrition, despite a lack of evidence about their effectiveness. In Niger, UCT and supplementary feeding are given during the June-September "lean season," although admissions of malnourished children to feeding programmes may rise from March/April. We hypothesised that earlier initiation of the UCT would reduce the prevalence of global acute malnutrition (GAM) in children 6-59 months old in beneficiary households and at population level. We conducted a 2-armed cluster-randomised controlled trial in which the poorest households received either the standard UCT (4 transfers between June and September) or a modified UCT (6 transfers from April); both providing 130,000 FCFA/£144 in total. Eligible individuals (pregnant and lactating women and children 6-<24 months old) in beneficiary households in both arms also received supplementary food between June and September. We collected data in March/April and October/November 2015. The modified UCT plus 4 months supplementary feeding did not reduce the prevalence of GAM compared with the standard UCT plus 4 months supplementary feeding (adjusted odds ratios 1.09 (95% CI [0.77, 1.55], p = 0.630) and 0.93 (95% CI [0.58, 1.49], p = 0.759) among beneficiaries and the population, respectively). More beneficiaries receiving the modified UCT plus supplementary feeding reported adequate food access in April and May (p < 0.001) but there was no difference in endline food security between arms. In both arms and samples, the baseline prevalence of GAM remained elevated at endline (p > 0.05), despite improved food security (p < 0.05), possibly driven by increased fever/malaria in children (p < 0.001). Nonfood related drivers of malnutrition, such as disease, may limit the effectiveness of UCTs plus supplementary feeding to prevent malnutrition in this context. Caution is required in applying the findings of this study to periods of severe food insecurity.

Addressing the double-burden of diabetes and tuberculosis: lessons from Kyrgyzstan.

BACKGROUND: The incidence of diabetes and tuberculosis co-morbidity is rising, yet little work has been done to understand potential implications for health systems, healthcare providers and individuals. Kyrgyzstan is a priority country for tuberculosis control and has a 5% prevalence of diabetes in adults, with many health system challenges for both conditions. METHODS: Patient exit interviews collected data on demographic and socio-economic characteristics, health spending and care seeking for people with diabetes, tuberculosis and both diabetes and tuberculosis. Qualitative data were collected through semi-structured interviews with healthcare workers involved in diabetes and tuberculosis care, to understand delivery of care and how providers view effectiveness of care. RESULTS: The experience of co-affected individuals within the health system is different than those just with tuberculosis or diabetes. Co-affected patients do not receive more care and also have different care for their tuberculosis than people with only tuberculosis. Very high levels of catastrophic spending are found among all groups despite these two conditions being included in the Kyrgyz state benefit package especially for medicines. CONCLUSIONS: This study highlights that different patterns of service provision by disease group are found. Although Kyrgyzstan has often been cited as an example in terms of health reforms and developing Primary Health Care, this study highlights the challenge of managing conditions that are viewed as "too complicated" for non-specialists and the impact this has on costs and management of individuals.

The REFANI-S study protocol: a non-randomised cluster controlled trial to assess the role of an unconditional cash transfer, a non-food item kit, and free piped water in reducing the risk of acute malnutrition among children aged 6-59 months living in camps for internally displaced persons in the Afgooye corridor, Somalia.

BACKGROUND: The prevalence of acute malnutrition is often high in emergency-affected populations and is associated with elevated mortality risk and long-term health consequences. Increasingly, cash transfer programmes (CTP) are used instead of direct food aid as a nutritional intervention, but there is sparse evidence on their nutritional impact. We aim to understand whether CTP reduces acute malnutrition and its known risk factors. METHODS/DESIGN: A non-randomised, cluster-controlled trial will assess the impact of an unconditional cash transfer of US$84 per month for 5 months, a single non-food items kit, and free piped water on the risk of acute malnutrition in children, aged 6-59 months. The study will take place in camps for internally displaced persons (IDP) in peri-urban Mogadishu, Somalia. A cluster will consist of one IDP camp and 10 camps will be allocated to receive the intervention based on vulnerability targeting criteria. The control camps will then be selected from the same geographical area. Needs assessment data indicates small differences in vulnerability between camps. In each trial arm, 120 households will be randomly sampled and two detailed household surveys will be implemented at baseline and 3 months after the initiation of the cash transfer. The survey questionnaire will cover risk factors for malnutrition including household expenditure, assets, food security, diet diversity, coping strategies, morbidity, WASH, and access to health care. A community surveillance system will collect monthly mid-upper arm circumference measurements from all children aged 6-59 months in the study clusters to assess the incidence of acute malnutrition over the duration of the intervention. Process evaluation data will be compiled from routine quantitative programme data and primary qualitative data collected using key informant interviews and focus group discussions. The UK Department for International Development will provide funding for this study. The European Civil Protection and Humanitarian Aid Operations will fund the intervention. Concern Worldwide will implement the intervention as part of their humanitarian programming. DISCUSSION: This non-randomised cluster controlled trial will provide needed evidence on the role of unconditional CTP in reducing the risk of acute malnutrition among IDP in this context. TRIAL REGISTRATION: ISRCTN29521514 . Registered 19 January 2016.

Sexual and reproductive health services utilization by female sex workers is context-specific: results from a cross-sectional survey in India, Kenya, Mozambique and South Africa.

BACKGROUND: Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, we identified gaps in service utilization in four different cities. METHODS: A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 'seeds' identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. RDS-adjusted proportions and surrounding 95% confidence intervals were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests with Dunn-Sidák correction. RESULTS: Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs' sociodemographic characteristics. CONCLUSION: The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. Intervention packages to improve use of contraceptives and SRH services should be tailored to the particular gaps in each city.

Protocol of the Low Birth Weight South Asia Trial (LBWSAT), a cluster-randomised controlled trial testing impact on birth weight and infant nutrition of Participatory Learning and Action through women's groups, with and without unconditional transfers of fortified food or cash during pregnancy in Nepal.

BACKGROUND: Low birth weight (LBW, < 2500 g) affects one third of newborn infants in rural south Asia and compromises child survival, infant growth, educational performance and economic prospects. We aimed to assess the impact on birth weight and weight-for-age Z-score in children aged 0-16 months of a nutrition Participatory Learning and Action behaviour change strategy (PLA) for pregnant women through women's groups, with or without unconditional transfers of food or cash to pregnant women in two districts of southern Nepal. METHODS: The study is a cluster randomised controlled trial (non-blinded). PLA comprises women's groups that discuss, and form strategies about, nutrition in pregnancy, low birth weight and hygiene. Women receive up to 7 monthly transfers per pregnancy: cash is NPR 750 (~US$7) and food is 10 kg of fortified sweetened wheat-soya Super Cereal per month. The unit of randomisation is a rural village development committee (VDC) cluster (population 4000-9200, mean 6150) in southern Dhanusha or Mahottari districts. 80 VDCs are randomised to four arms using a participatory 'tombola' method. Twenty clusters each receive: PLA; PLA plus food; PLA plus cash; and standard care (control). Participants are (mostly Maithili-speaking) pregnant women identified from 8 weeks' gestation onwards, and their infants (target sample size 8880 birth weights). After pregnancy verification, mothers may be followed up in early and late pregnancy, within 72 h, after 42 days and within 22 months of birth. Outcomes pertain to the individual level. Primary outcomes include birth weight within 72 h of birth and infant weight-for-age Z-score measured cross-sectionally on children born of the study. Secondary outcomes include prevalence of LBW, eating behaviour and weight during pregnancy, maternal and newborn illness, preterm delivery, miscarriage, stillbirth or neonatal mortality, infant Z-scores for length-for-age and weight-for-length, head circumference, and postnatal maternal BMI and mid-upper arm circumference. Exposure to women's groups, food or cash transfers, home visits, and group interventions are measured. DISCUSSION: Determining the relative importance to birth weight and early childhood nutrition of adding food or cash transfers to PLA women's groups will inform design of nutrition interventions in pregnancy. TRIAL REGISTRATION: ISRCTN75964374 , 12 Jul 2013.

Are village health sanitation and nutrition committees fulfilling their roles for decentralised health planning and action? A mixed methods study from rural eastern India.

BACKGROUND: In India, Village Health Sanitation and Nutrition Committees (VHSNCs) are participatory community health forums, but there is little information about their composition, functioning and effectiveness. Our study examined VHSNCs as enablers of participatory action for community health in two rural districts in two states of eastern India - West Singhbhum in Jharkhand and Kendujhar, in Odisha. METHODS: We conducted a cross-sectional survey of 169 VHSNCs and ten qualitative focus group discussions with purposively selected better and poorer performing committees, across the two states. We analysed the quantitative data using descriptive statistics and the qualitative data using a Framework approach. RESULTS: We found that VHSNCs comprised equitable representation from vulnerable groups when they were formed. More than 75 % members were women. Almost all members belonged to socially disadvantaged classes. Less than 1 % members had received any training. Supervision of committees by district or block officials was rare. Their work focused largely on strengthening village sanitation, conducting health awareness activities, and supporting medical treatment for ill or malnourished children and pregnant mothers. In reality, 62 % committees monitored community health workers, 6.5 % checked sub-centres and 2.4 % monitored drug availability with community health workers. Virtually none monitored data on malnutrition. Community health and nutrition workers acted as conveners and record keepers. Links with the community involved awareness generation and community monitoring of VHSNC activities. Key challenges included irregular meetings, members' limited understanding of their roles and responsibilities, restrictions on planning and fund utilisation, and weak linkages with the broader health system. CONCLUSIONS: Our study suggests that VHSNCs perform few of their specified functions for decentralized planning and action. If VHSNCs are to be instrumental in improving community health, sanitation and nutrition, they need education, mobilisation and monitoring for formal links with the wider health system.

Is the Job Satisfaction Survey a good tool to measure job satisfaction amongst health workers in Nepal? Results of a validation analysis.

BACKGROUND: Job satisfaction is an important predictor of an individual's intention to leave the workplace. It is increasingly being used to consider the retention of health workers in low-income countries. However, the determinants of job satisfaction vary in different contexts, and it is important to use measurement methods that are contextually appropriate. We identified a measurement tool developed by Paul Spector, and used mixed methods to assess its validity and reliability in measuring job satisfaction among maternal and newborn health workers (MNHWs) in government facilities in rural Nepal. METHODS: We administered the tool to 137 MNHWs and collected qualitative data from 78 MNHWs, and district and central level stakeholders to explore definitions of job satisfaction and factors that affected it. We calculated a job satisfaction index for all MNHWs using quantitative data and tested for validity, reliability and sensitivity. We conducted qualitative content analysis and compared the job satisfaction indices with qualitative data. RESULTS: Results from the internal consistency tests offer encouraging evidence of the validity, reliability and sensitivity of the tool. Overall, the job satisfaction indices reflected the qualitative data. The tool was able to distinguish levels of job satisfaction among MNHWs. However, the work environment and promotion dimensions of the tool did not adequately reflect local conditions. Further, community fit was found to impact job satisfaction but was not captured by the tool. The relatively high incidence of missing responses may suggest that responding to some statements was perceived as risky. CONCLUSION: Our findings indicate that the adapted job satisfaction survey was able to measure job satisfaction in Nepal. However, it did not include key contextual factors affecting job satisfaction of MNHWs, and as such may have been less sensitive than a more inclusive measure. The findings suggest that this tool can be used in similar settings and populations, with the addition of statements reflecting the nature of the work environment and structure of the local health system. Qualitative data on job satisfaction should be collected before using the tool in a new context, to highlight any locally relevant dimensions of job satisfaction not already captured in the standard survey.

Measurement and valuation of health providers' time for the management of childhood pneumonia in rural Malawi: an empirical study.

BACKGROUND: Human resources are a major cost driver in childhood pneumonia case management. Introduction of 13-valent pneumococcal conjugate vaccine (PCV-13) in Malawi can lead to savings on staff time and salaries due to reductions in pneumonia cases requiring admission. Reliable estimates of human resource costs are vital for use in economic evaluations of PCV-13 introduction. METHODS: Twenty-eight severe and twenty-four very severe pneumonia inpatients under the age of five were tracked from admission to discharge by paediatric ward staff using self-administered timesheets at Mchinji District Hospital between June and August 2012. All activities performed and the time spent on each activity were recorded. A monetary value was assigned to the time by allocating a corresponding percentage of the health workers' salary. All costs are reported in 2012 US$. RESULTS: A total of 1,017 entries, grouped according to 22 different activity labels, were recorded during the observation period. On average, 99 min (standard deviation, SD = 46) were spent on each admission: 93 (SD = 38) for severe and 106 (SD = 55) for very severe cases. Approximately 40 % of activities involved monitoring and stabilization, including administering non-drug therapies such as oxygen. A further 35 % of the time was spent on injecting antibiotics. Nurses provided 60 % of the total time spent on pneumonia admissions, clinicians 25 % and support staff 15 %. Human resource costs were approximately US$ 2 per bed-day and, on average, US$ 29.5 per severe pneumonia admission and US$ 37.7 per very severe admission. CONCLUSIONS: Self-reporting was successfully used in this context to generate reliable estimates of human resource time and costs of childhood pneumonia treatment. Assuming vaccine efficacy of 41 % and 90 % coverage, PCV-13 introduction in Malawi can save over US$ 2 million per year in staff costs alone.

Coping with the economic burden of Diabetes, TB and co-prevalence: evidence from Bishkek, Kyrgyzstan.

BACKGROUND: The increasing number of patients co-affected with Diabetes and TB may place individuals with low socio-economic status at particular risk of persistent poverty. Kyrgyz health sector reforms aim at reducing this burden, with the provision of essential health services free at the point of use through a State-Guaranteed Benefit Package (SGBP). However, despite a declining trend in out-of-pocket expenditure, there is still a considerable funding gap in the SGBP. Using data from Bishkek, Kyrgyzstan, this study aims to explore how households cope with the economic burden of Diabetes, TB and co-prevalence. METHODS: This study uses cross-sectional data collected in 2010 from Diabetes and TB patients in Bishkek, Kyrgyzstan. Quantitative questionnaires were administered to 309 individuals capturing information on patients' socioeconomic status and a range of coping strategies. Coarsened exact matching (CEM) is used to generate socio-economically balanced patient groups. Descriptive statistics and logistic regression are used for data analysis. RESULTS: TB patients are much younger than Diabetes and co-affected patients. Old age affects not only the health of the patients, but also the patient's socio-economic context. TB patients are more likely to be employed and to have higher incomes while Diabetes patients are more likely to be retired. Co-affected patients, despite being in the same age group as Diabetes patients, are less likely to receive pensions but often earn income in informal arrangements. Out-of-pocket (OOP) payments are higher for Diabetes care than for TB care. Diabetes patients cope with the economic burden by using social welfare support. TB patients are most often in a position to draw on income or savings. Co-affected patients are less likely to receive social welfare support than Diabetes patients. Catastrophic health spending is more likely in Diabetes and co-affected patients than in TB patients. CONCLUSIONS: This study shows that while OOP are moderate for TB affected patients, there are severe consequences for Diabetes affected patients. As a result of the underfunding of the SGBP, Diabetes and co-affected patients are challenged by OOP. Especially those who belong to lower socio-economic groups are challenged in coping with the economic burden.

Self-transfer and mortality amongst adults lost to follow-up in ART programmes in low- and middle-income countries: systematic review and meta-analysis.

OBJECTIVE: To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low- and middle-income countries. METHODS: PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003-2013) and IAS/AIDS conference abstracts (2011-2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses. RESULTS: Twenty eight studies were eligible for inclusion, reporting true outcomes for 10,806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. Twenty three studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of self-transfer and LTFU in the ART cohort. The pooled estimates for unreported deaths were 38.8% (95% CI 30.8-46.8%; 27 studies) and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31 December 2007. CONCLUSIONS: Substantial unaccounted for transfers and deaths amongst patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained.

Inequity in costs of seeking sexual and reproductive health services in India and Kenya.

OBJECTIVE: This study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending. METHODS: Data for this study were collected as a part of the situational analysis for the "Diagonal Interventions to Fast Forward Enhanced Reproductive Health" (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10% of total household income. RESULTS: The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2% and 0.03-7.5% in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were "receiving [money] from partner or household members" (69%) and "using own savings or regular income" (44%), respectively. CONCLUSION: Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.

Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi.

BACKGROUND: Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale. METHODS: Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $. RESULTS: The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi. CONCLUSIONS: Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.

Validating a tool to measure auxiliary nurse midwife and nurse motivation in rural Nepal.

BACKGROUND: A global shortage of health workers in rural areas increases the salience of motivating and supporting existing health workers. Understandings of motivation may vary in different settings, and it is important to use measurement methods that are contextually appropriate. We identified a measurement tool, previously used in Kenya, and explored its validity and reliability to measure the motivation of auxiliary nurse midwives (ANM) and staff nurses (SN) in rural Nepal. METHOD: Qualitative and quantitative methods were used to assess the content validity, the construct validity, the internal consistency and the reliability of the tool. We translated the tool into Nepali and it was administered to 137 ANMs and SNs in three districts. We collected qualitative data from 78 nursing personnel and district- and central-level stakeholders using interviews and focus group discussions. We calculated motivation scores for ANMs and SNs using the quantitative data and conducted statistical tests for validity and reliability. Motivation scores were compared with qualitative data. Descriptive exploratory analysis compared mean motivation scores by ANM and SN sociodemographic characteristics. RESULTS: The concept of self-efficacy was added to the tool before data collection. Motivation was revealed through conscientiousness. Teamwork and the exertion of extra effort were not adequately captured by the tool, but important in illustrating motivation. The statement on punctuality was problematic in quantitative analysis, and attendance was more expressive of motivation. The calculated motivation scores usually reflected ANM and SN interview data, with some variation in other stakeholder responses. The tool scored within acceptable limits in validity and reliability testing and was able to distinguish motivation of nursing personnel with different sociodemographic characteristics. CONCLUSIONS: We found that with minor modifications, the tool provided valid and internally consistent measures of motivation among ANMs and SNs in this context. We recommend the use of this tool in similar contexts, with the addition of statements about self-efficacy, teamwork and exertion of extra effort. Absenteeism should replace the punctuality statement, and statements should be worded both positively and negatively to mitigate positive response bias. Collection of qualitative data on motivation creates a more nuanced understanding of quantitative scores.