Determinants of skilled birth attendance in rural Cambodia.

OBJECTIVE: To identify the determinants of skilled and unskilled birth attendance. METHOD: Population-based survey in a rural area in Cambodia, of women aged 15-49 years who had delivered during the previous 3-month period. An analytical framework based on Andersen's behavioural model served to identify determinants according to delivery place (facility vs. non-facility), birth attendant at home births (skilled vs. unskilled), and change of birth attendant during delivery (changed vs. unchanged). We used logistic regression to analyse the data. RESULTS: Of 980 women included in the analyses, 19.8% had skilled attendants present during delivery. The determinants of facility delivery were different from those for having skilled attendants assisting in home births. In case of facility deliveries, previous contact with a skilled attendant through antenatal care was a significant determinant. In case of home births, the type of birth attendant (i.e. skilled or unskilled) at the preceding delivery was a significant determinant. CONCLUSION: Community-based programmes need to reach primiparas, because once a woman has delivered with the aid of an unskilled attendant, she is five to seven times less likely to seek skilled help than a primipara.

Validity and reliability of the Bangla version of WHOQOL-BREF on an adolescent population in Bangladesh.

The objectives of this study were to develop a Bangla version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF), and assess its reliability and validity on an adolescent population in Bangladesh. In total, 187 boys (mean age 14.6 years +/- SD 2.1) and 137 girls (15.2 +/- SD 2.0) from residential areas, and 157 boys (13.8 +/- SD 2.1) and 121 girls (13.4 +/- SD 2.1) from slums in Dhaka were interviewed using a questionnaire, which included a Bangla translation of the WHOQOL-BREF. Thirty-eight randomly selected adolescents from the original interviewed group were re-administered the same questionnaire 1 week later. On the whole, the Bangla version of WHOQOL-BREF showed good internal consistency and test-retest reliability. In comparisons between residential and slum areas, discriminant validities were observed in the total and environmental domain of both genders and in the social relationship domain of males. Furthermore, discriminant validities of physical and psychological domains were observed in gender comparisons. These results suggest that the Bangla version of WHOQOL-BREF is valid and reliable in assessing the quality of life of adolescents in Bangladesh.

Community perception and readiness for anti-helminth programmes in rural Nepal.

We report on the community perception of helminth infection and readiness to participate in and pay for a community-based anti-helminth programme in rural Nepal. For data collection, 28 focus group discussions (FGDs) were conducted in 28 communities. The FGD results revealed that community members were lacking in scientific knowledge about helminth infection. They also had an unusual perception about it--they believed that a 'mul juka' (vital worm) should reside in every person's stomach from birth, and must never be killed. Nonetheless, the results showed that the community members were willing to participate in and were ready to contribute their resources to the anti-helminth programmes as long as modern medicine would not kill the 'mul juka'. Such community readiness provides us with hope for developing a sustainable anti-helminth programme at the community level through effective health education.

The need for linking healthcare-seeking behavior and health policy in rural Nepal.

In Nepal, little emphasis has been placed on the need to link healthcare-seeking behavior (HCSB) with health policy. The purpose of this study is to identify the HCSB of 405 households that were randomly selected from 28 communities in a hilly region of central Nepal. In assessing HCSB, we found that some form of illness strikes about 50% of households each year. When rural Nepalese are moderately or severely ill, they seek healthcare from traditional healers first, before visiting other health workers. Mild illnesses are treated at home. To improve the health of the rural population, health planners should recognize these realities and incorporate them into the development of health policies.

Life and death of children: the price of life.

Nearly 2 million children die of simple diarrhea each year in developing countries. Those children would not have died if they were given Oral Rehydration Solution, which costs 100 yen for treating one child. In developed countries like Japan, treating one patient with intracranial aneurysm will cost over 2 million yen. The cost for treating one such patient could save 10,000 children with diarrhea even after adjusting with purchasing power parity in developing countries. Such inequity and inequality cannot be acceptable. We who are concerned about such a status quo have to work together for the betterment of children living in developing countries. In this review the author explores the root causes behind such unjust global structures.

[Shifting of emphasis in the world health sector strategy; from political concerns to economic ones].

Primary Health Care, proclaimed by WHO in 1978, is a health strategy that aims to achieve the ultimate objective "Health For All", with underlying political concerns for ideals such as social justice, equity and human rights. Meanwhile, "globalization", urged by the U.S.A., other developed countries and multinational corporations, has since promoted liberalization of trade, capital and finance, which has in the past few decades been sweeping all over the world. With this "new economic liberalism", values that put much emphasis on economic efficiency are now at the forefront. The World Bank, which supports the tendency along with the International Monetary Fund and the World Trade Organization, has become an influential actor in helping developing countries to prosper economically. The World Bank, whose basic idea is that investment in health is basic for economic growth, has in the 1990s also exerted considerable influence on the international health sector with its overwhelming provision of financial assistance. Instead of political concerns like equity and human rights, 'economic concerns' such as fairer budget allocation, cost-effectiveness, cost reduction and efficiency have now become main points for discussion in the international health field. This shift in emphasis poses fundamental questions for the core goal of the World Health Organization; "Health For All".

Cost-effectiveness of community health workers in tuberculosis control in Bangladesh.

OBJECTIVE: To compare the cost-effectiveness of the tuberculosis (TB) programme run by the Bangladesh Rural Advancement Committee (BRAC), which uses community health workers (CHWs), with that of the government TB programme which does not use CHWs. METHODS: TB control statistics and cost data for July 1996 - June 1997 were collected from both government and BRAC thanas (subdistricts) in rural Bangladesh. To measure the cost per patient cured, total costs were divided by the total number of patients cured. FINDINGS: In the BRAC and government areas, respectively, a total of 186 and 185 TB patients were identified over one year, with cure rates among sputum-positive patients of 84% and 82%. However, the cost per patient cured was US$ 64 in the BRAC area compared to US$ 96 in the government area. CONCLUSION: The government programme was 50% more expensive for similar outcomes. Although both the BRAC and government TB control programmes appeared to achieve satisfactory cure rates using DOTS (a five-point strategy), the involvement of CHWs was found to be more cost-effective in rural Bangladesh. With the same budget, the BRAC programme could cure three TB patients for every two in the government programme.