Mobilizing communities to improve maternal health: results of an intervention in rural Zambia.

OBJECTIVE: To determine whether a complex community intervention in rural Zambia improved understanding of maternal health and increased use of maternal health-care services. METHODS: The intervention took place in six rural districts selected by the Zambian Ministry of Health. It involved community discussions on safe pregnancy and delivery led by trained volunteers and the provision of emergency transport. Volunteers worked through existing government-established Safe Motherhood Action Groups. Maternal health indicators at baseline were obtained from women in intervention (n = 1775) and control districts (n = 1630). The intervention's effect on these indicators was assessed using a quasi-experimental difference-in-difference approach that involved propensity score matching and adjustment for confounders such as education, wealth, parity, age and distance to a health-care facility. FINDINGS: The difference-in-difference comparison showed the intervention to be associated with significant increases in maternal health indicators: 14-16% in the number of women who knew when to seek antenatal care; 10-15% in the number who knew three obstetric danger signs; 12-19% in those who used emergency transport; 22-24% in deliveries involving a skilled birth attendant; and 16-21% in deliveries in a health-care facility. The volunteer drop-out rate was low. The estimated incremental cost per additional delivery involving a skilled birth attendant was around 54 United States dollars, comparable to that of other demand-side interventions in developing countries. CONCLUSION: The community intervention was associated with significant improvements in women's knowledge of antenatal care and obstetric danger signs, use of emergency transport and deliveries involving skilled birth attendants.

Participatory impact assessment of soil and water conservation scenarios in Oum Zessar watershed, Tunisia.

Environmental threats and progressive degradation of natural resources are considered critical impediments to sustainable development. This paper reports on a participatory impact assessment of alternative soil and water conservation (SWC) scenarios in the Oum Zessar watershed, Tunisia. The first objective was to assess the impact of three SWC scenarios on key social, economic and environmental land use functions. The second objective was to test and evaluate the applicability of the 'Framework for Participatory Impact Assessment (FoPIA)' for assessing scenario impacts in the context of a developing country, in this case Tunisia. The assessed scenarios included: the originally planned SWC policy implementation at 85 % coverage of arable land of the watershed, the current implementation (70 %), and a hypothetical expansion of SWC measures to the entire watershed (100 %). Our results suggest that implementation of the SWC policy at 100 % coverage of arable land achieves the maximum socioeconomic benefit. However, if stakeholders' preferences regarding land use functions are taken into account, and considering the fact that the implementation of SWC measures also implies some negative changes to traditional landscapes and the natural system, SWC implementation at 85 % coverage of arable land might be preferable. The FoPIA approved to be a useful tool for conducting a holistic sustainability impact assessment of SWC scenarios and for studying the most intriguing sustainability problems while providing possible recommendations towards sustainable development. We conclude that participatory impact assessment contributes to an enhanced regional understanding of key linkages between policy effects and sustainable development, which provides the foundation for improved policy decision making.

Task shifting in maternal and child health care: an evidence brief for Uganda.

THE PROBLEM: There is a shortage and maldistribution of medically trained health professionals to deliver cost-effective maternal and child health (MCH) services. Hence, cost-effective MCH services are not available to over half the population of Uganda and progress toward the Millennium Development Goals for MCH is slow. Optimizing the roles of less specialized health workers ("task shifting") is one strategy to address the shortage and maldistribution of more specialized health professionals. POLICY OPTIONS: (i) Lay health workers (community health workers) may reduce morbidity and mortality in children under five and neonates; and training for traditional birth attendants may improve perinatal outcomes and appropriate referrals. (ii) Nursing assistants in facilities might increase the time available from nurses, midwives, and doctors to provide care that requires more training. (iii) Nurses and midwives to deliver cost-effective MCH interventions in areas where there is a shortage of doctors. (iv) Drug dispensers to promote and deliver cost-effective MCH interventions and improve the quality of the services they provide. The costs and cost-effectiveness of all four options are uncertain. Given the limitations of the currently available evidence, rigorous evaluation and monitoring of resource use and activities is warranted for all four options. IMPLEMENTATION STRATEGIES: A clear policy on optimizing health worker roles. Community mobilization and reduction of out-of-pocket costs to improve mothers' knowledge and care-seeking behaviors, continuing education, and incentives to ensure health workers are competent and motivated, and community referral and transport schemes for MCH care are needed.

Willingness to pay among households to prevent coastal resources from polluting by oil spills: a pilot survey.

In many coastal regions oil spills can be considered to be one of the most important risks for the coastal environment. Efficient contingency management in responding to oil spills is critically important. Strategic priorities in contingency management highly depend upon the importance attributed to different economic and ecological resources such as beaches or birds. Due to the lack of a market for natural resources in the real world, these resources cannot be directly measured in monetary terms. This increases the risk that natural resources and their services are neglected in contingency decision making. This paper evaluates these natural resources in a hypothetical market by using the methodology of stated choice experiments. Results from a pilot survey show that according to the perspective of individuals, an oil spill combat process should focus on the protection of coastal waters, beaches and eider ducks.

[Competition in healthcare--a health systems' perspective]. / Wettbewerb im Gesundheitswesen--eine Gesundheitssystemperspektive.

That "more competition in healthcare primarily produces more needs-based equity, better quality, higher efficiency, reduced costs and less bureaucracy" is a familiar claim. But is it correct? Three types of competition can be identified within a triangle: (1) competition among third-party-payers for insured individuals/customers, (2) competition among providers for patients, and (3) competition among third-party payers for contracts with providers--and vice versa. German and international evidence for these three types of competition demonstrates that many expectations--e.g., that patients can be steered based on quality information--are wishful thinking. Instead of market and competition, regulation is needed (e.g., in the form of an effective risk-based allocation mechanism) to ensure high-quality care for those 5% of the population incurring 50% of the healthcare expenditures (i.e., the seriously ill patients), while at the same time competition based on selective contracts does not pay off for the majority of the population due to high transaction costs.

Strategic positioning. Part 1: The sources of value under managed care.

Part 1 of this series organizes and discusses the sources of value against a background of an evolving managed care market. Part 2 will present, in more detail, the marketing and financial challenges to organizational positioning and performance across the four stages of managed care. What are the basic principles or tenets of value and how do they apply to the health care industry? Why is strategic positioning so important to health care organizations struggling in a managed care environment and what are the sources of value? Service motivated employees and the systems that educate them represent a stronger competitive advantage than having assets and technology that are available to anyone. As the health care marketplace evolves, organizations must develop a strategic position that will provide such value and for which the customer will be willing to pay.

Integrated local health systems in Central America.

This paper describes a few Central American experiences related to the development of integrated, participatory health care systems. Theory and analytic method center on the tensions inherent in the dichotomies of professional/popular, center/periphery and biomedical/traditional. Using a framework rooted in the World Health Organization's 1978 call for 'health for all' based on community-oriented primary care, this paper concludes that the underlying conditions necessary for truly integrated local health systems have not yet developed. Except for the cases of Costa Rica during 1978-1982 and Nicaragua during 1979-1990, the political will to create and support such systems has not existed. Perhaps more importantly, the cultural milieu in which Central Americans interact with their society fosters an individualistic, commercial, and paternalistic citizen/society relationship rather than the cooperative, community-oriented and democratic spirit needed for successful development of integrated local health systems. Nevertheless, there are a number of positive examples from which we can learn, and a growing tradition of citizen participation which may lead toward appropriate, sustainable, and truly integrated local health systems.

Primary health care, community participation and community-financing: experiences of two middle hill villages in Nepal.

Although community involvement in health related activities is generally acknowledged by international and national health planners to be the key to the successful organization of primary health care, comparatively little is known about its potential and limitations. Drawing on the experiences of two middle hill villages in Nepal, this paper reports on research undertaken to compare and contrast the scope and extent of community participation in the delivery of primary health care in a community run and financed health post and a state run and financed health post. Unlike many other health posts in Nepal these facilities do provide effective curative services, and neither of them suffer from chronic shortage of drugs. However, community-financing did not appear to widen the scope and the extent of participation. Villagers in both communities relied on the health post for the treatment of less than one-third of symptoms, and despite the planners' intentions, community involvement outside participation in benefits was found to be very limited.

PIP: During the summer of 1992, data were gathered through household and personal interviews in two isolated villages in western Nepal to compare a state- and a community-sponsored health center. The Ghandruk Community Health Centre was established in 1987 by a local nongovernmental organization (NGOs) and the Sikles health post was established by the Indian government in the mid-1950s. A comparison of the health-seeking behavior in each village showed that both health centers accounted for only about 30% of treatment, that 40% of illnesses were self-treated, and that 26% of illness in Ghandruk and 35% in the poorer Sikles remained untreated. In each village, more than 90% of the sample was unaware of the existence of a health committee and the health committees were afforded very low status compared to other committees (such as the forest committee). Health committee members were more active in Sikles despite the fact that the health post was controlled by district/regional health authorities. Health workers were more readily identified than members of the health committees but they performed only a few of their educational and health promotional tasks. Village health workers appeared to be inactive, and none of the trained traditional birth attendants were practicing. While the two villages showed no differences in participation in the delivery and use of health services, villagers in Ghandruk have been active in health-related activities such as the construction of private latrines, the development of a water supply, and regular clean-up campaigns. In Sikles, where such interventions have yet to be accomplished, the morbidity rate in the sample population was 81%, compared with 23.9% for Ghandruk. These results lead to the following observations: 1) the applicability of a participatory approach to development in rural Nepal is questionable from a cross-cultural perspective, and 2) the existence of socioeconomic and cultural hierarchies in the villages combined with male domination of the health committees prevents health committees from representing the needs of the entire community. In conclusion, community financing did not appear to increase community participation in the delivery and use of health services or to result in greater equity in health care. Rather than leading to abandonment of this financing option, however, these results should help lead to the creation of a proper balance between the role of government, NGOs, and community self-help in the delivery of health care.

An alternative framework for evaluating welfare losses in the health care market.

A recurring theme in the health economics literature is that 'excess' health insurance reduces society's welfare. This proposition is considered to be a truism by most health economists. Feldman and Morrisey (1990) report that two-thirds of American and Canadian health economists surveyed agree with the statement that, 'the level and type of health insurance held by most U.S. families generate substantial welfare loss due to over-consumption of medical services'. Consequently, most research in the area has attempted to identify the exact dollar value of this welfare loss. In this note, I will try to show that the traditional method of calculating welfare losses from excess health insurance is severely flawed because it is based on assumptions about consumer behavior that are not supported by the available empirical evidence. Furthermore, the methodology masks other, potentially greater societal welfare losses that are likely to exist in the health care sector, and blinds us from seeking the most effective public policy remedies. This note suggests an alternative framework for considering welfare losses based on researchers' evaluations of medical necessity.