Supply-Side Barriers to Maternity-Care in India: A Facility-Based Analysis

Background

Health facilities in many low- and middle-income countries face several types of barriers in delivering quality health services. Availability of resources at the facility may significantly affect the volume and quality of services provided. This study investigates the effect of supply-side determinants of maternity-care provision in India.

Methods

Health facility data from the District-Level Household Survey collected in 2007–2008 were analyzed to explore the effects of supply-side factors on the volume of delivery care provided at Indian health facilities. A negative binomial regression model was applied to the data due to the count and over-dispersion property of the outcome variable (number of deliveries performed at the facility).

Results

Availability of a labor room (Incidence Rate Ratio [IRR]: 1.81; 95% Confidence Interval [CI]: 1.68–1.95) and facility opening hours (IRR: 1.43; CI: 1.35–1.51) were the most significant predictors of the volume of delivery care at the health facilities. Medical and paramedical staff were found to be positively associated with institutional deliveries. The volume of deliveries was also higher if adequate beds, essential obstetric drugs, medical equipment, electricity, and communication infrastructures were available at the facility. Findings were robust to the inclusion of facility''s catchment area population and district-level education, health insurance coverage, religion, wealth, and fertility. Separate analyses were performed for facilities with and without a labor room and results were qualitatively similar across these two types of facilities.

Conclusions

Our study highlights the importance of supply-side barriers to maternity-care India. To meet Millennium Development Goals 4 and 5, policymakers should make additional investments in improving the availability of medical drugs and equipment at primary health centers (PHCs) in India.     

A comparison between Northern and Southern Hemisphere tundras and related ecosystems

Summary Climatic, edaphic, and vegetation parameters are compared among three Subantarctic islands and one Maritime Antarctic island, and Northern Hemisphere tundras and tundra-like ecosystems (ranging from higharctic to cool-temperate oceanic and temperate alpine), mainly by Principal Component Analyses (PCA). All analyses of abiotic variables emphasized the extreme oceanicity of the Southern Hemisphere sites and showed the strong influence of seaspray on soil nutrient ratios in the southern sites. Analyses of climate classified all the southern sites as Cold Oceanic within a series of very oceanic climates that were distinct from the continental/subalpine climates more typical of the northern sites. Four factorial groups were derived from the vectors in PCA of soils and climate combined. Each was a grouping of several variables that was essentially independent of the other groups. They were: general climatic severity, soil base status, supply of labile nutrients, and a combined index of oceanicity with organic/mineral balance and drainage. The ecological significance of these is discussed. The range of soil nutrient levels in the southern sites is approximately equal to that of the northern sites; however, in the southern sites soil nutrient levels are inversely related to climatic severity while in the north the reverse is true. The two most important causes of these opposed trends are the relative ages of the sites and the much greater effects of sea-based vertebrates (e.g. seals and seabirds) in the southern islands. Cluster analyses of component scores derived from climatic and soil data linked the southern sites with northern sites at higher latitudes, indicating the effect of the Antarctic continent on the Southern Ocean (hence on the overall climate of the southern islands) and of wind-chill on the aerial and soil climates of the southern sites. Vegetation patterns (derived from PCA of life form data) were more complex because of the serial replacement of one lifeform by onother along continuous environmental gradients. Wind exposure was an important element in the first two vectors derived from the PCA of the botanical data. The Southern Hemisphere sites exhibited almost the full range of vegetation types found in the Northern Hemisphere, despite their floristic poverty. Variation within individual islands was comparable with that found at considerably higher (up to 30° more) northern latitudes and reflects the overriding importance of wind exposure in the southern islands. Subarctic ecosystems are generally less severe forms of Arctic ones, and decreasing latitude leads to increasingly milder environments with no great changes overall in continentality. In contrast, the Subantarctic combines elements from the extremes of the range of northen tundras (i.e. high-Arctic and cool-temperate oceanic) with its own peculiar features (e.g. animal influences) to produce ecosystems that are qualitatively different both from Subarctic systems and from the continental Antarctic regions to which they are geographically closest.     

Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis

BackgroundHealth services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends.Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.ConclusionsThe study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.     

Cost-Effectiveness Analysis of Three Leprosy Case Detection Methods in Northern Nigeria

Background

Despite several leprosy control measures in Nigeria, child proportion and disability grade 2 cases remain high while new cases have not significantly reduced, suggesting continuous spread of the disease. Hence, there is the need to review detection methods to enhance identification of early cases for effective control and prevention of permanent disability. This study evaluated the cost-effectiveness of three leprosy case detection methods in Northern Nigeria to identify the most cost-effective approach for detection of leprosy.

Methods

A cross-sectional study was carried out to evaluate the additional benefits of using several case detection methods in addition to routine practice in two north-eastern states of Nigeria. Primary and secondary data were collected from routine practice records and the Nigerian Tuberculosis and Leprosy Control Programme of 2009. The methods evaluated were Rapid Village Survey (RVS), Household Contact Examination (HCE) and Traditional Healers incentive method (TH). Effectiveness was measured as number of new leprosy cases detected and cost-effectiveness was expressed as cost per case detected. Costs were measured from both providers'' and patients'' perspectives. Additional costs and effects of each method were estimated by comparing each method against routine practise and expressed as incremental cost-effectiveness ratio (ICER). All costs were converted to the U.S. dollar at the 2010 exchange rate. Univariate sensitivity analysis was used to evaluate uncertainties around the ICER.

Results

The ICER for HCE was $142 per additional case detected at all contact levels and it was the most cost-effective method. At ICER of $194 per additional case detected, THs method detected more cases at a lower cost than the RVS, which was not cost-effective at $313 per additional case detected. Sensitivity analysis showed that varying the proportion of shared costs and subsistent wage for valuing unpaid time did not significantly change the results.

Conclusion

Complementing routine practice with household contact examination is the most cost-effective approach to identify new leprosy cases and we recommend that, depending on acceptability and feasibility, this intervention is introduced for improved case detection in Northern Nigeria.     

Out-of-Pocket Payments,Health Care Access and Utilisation in South-Eastern Nigeria: A Gender Perspective

Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by using a combination of quantitative and qualitative analysis to investigate the gendered impact of OOPs on healthcare utilisation in south-eastern Nigeria. 411 households were surveyed and six single-sex Focus Group Discussions conducted. This study confirmed the socioeconomic and demographic vulnerability of female-headed households (FHHs), which contributed to gender-based inter-household differences in healthcare access, cost burden, choices of healthcare providers, methods of funding healthcare and coping strategies. FHHs had higher cost burdens from seeking care and untreated morbidity than male-headed households (MHHs) with affordability as a reason for not seeking care. There is also a high utilisation of patent medicine vendors (PMVs) by both households (PMVs are drug vendors that are unregulated, likely to offer very low-quality treatment and do not have trained personnel). OOP payment was predominantly the means of healthcare payment for both households, and households spoke of the difficulties associated with repaying health-related debt with implications for the medical poverty trap. It is recommended that the removal of user fees, introduction of prepayment schemes, and regulating PMVs be considered to improve access and provide protection against debt for FHHs and MHHs. The vulnerability of widows is of special concern and efforts to improve their healthcare access and broader efforts to empower should be encouraged for them and other poor households.     

Vegetation analogs and differences in the Northern and Southern Hemispheres: A global comparison

Biogeographic comparisons help to identify similarities, differences, larger contexts, and useful hypotheses. Between the (extra-tropical) Northern and Southern Hemispheres taxonomy differs almost completely, but other useful bases for vegetation comparison include phenophysiognomy, form composition and vegetation architecture, subphysiognomic morphology, environmental limits of plant types, taxonomic richness, and some aspects of function. All major biome types occur in both hemispheres except the boreal forests and analogous montane coniferous forests of the Northern Hemisphere. Some vegetation and plant types appear clearly unique, including Eucalyptus, campo cerrado, and flat-cushions such as Azorella, all of these in the Southern Hemisphere. Different but parallel adaptations to different but analogous conditions include the tall submediterranean forests, temperate rainforests, and continental versus maritime temperate deserts. Climatic limits appear similar in the two hemispheres, but mechanisms for some differences remain unresolved. Per unit land area, the Southern Hemisphere has higher annual net primary productivity than the Northern. Dissimilar analogs continue to suggest hypotheses and research questions.     

Bovine streptothricosis and reproduction in Northern Nigeria: a case study

A group of cows, which were naturally infected with streptothricosis, was observed for 17 months. The genitalia were examined per rectum, at least twice monthly to determine the ovarian activity. During the period of observation, 83.3% of the lightly affected cows were pregnant or had calves, while only 33.3% of the moderately/severely affected cows had calves. It is suggested that streptothricosis, like any other debilitating disease, affects reproductive performance, and in the case of severe, localized, perineal infection, the disease results in mechanical interference with mating.     

Phylogeny of the leafy liverwort Ptilidium: cryptic speciation and shared haplotypes between the Northern and Southern Hemispheres

The small, phylogenetically isolated liverwort genus Ptilidium has been regarded as of cool-Gondwanic origin with the bipolar, terrestrial Ptilidium ciliare giving rise to the Northern Hemisphere epiphytes Ptilidium pulcherrimum and Ptilidium californicum. This hypothesis is examined using a dataset including three chloroplast DNA regions from 134 Ptilidium accessions and one accession each of its closest relatives Trichocoleopsis and Neotrichocolea. Maximum likelihood and parsimony analyses point to a close relationship between P. ciliare and P. pulcherrimum, whereas P. californicum is placed sister to the remainder of the genus, separated by a long branch. Haplotype analysis and our phylogeny indicate the presence of Southern Hemisphere haplotypes of P. ciliare in the Northern Hemisphere, and shared haplotypes of P. ciliare and P. pulcherrimum between Europe and North America. Based on our findings, we reject the Gondwana-scenario and propose recent long distance dispersal as an explanation for the bipolar disjunct range. Ptilidium ciliare is resolved as paraphyletic with P. pulcherrimum nested within it. An isolated Ptilidium lineage with the morphology of P. ciliare from the Himalaya region likely represents a hitherto unrecognized cryptic species. Ptilidium pulcherrimum splits into a Japanese clade and a clade with accessions from Europe and North America.     

Drinking water quality and risk implications for community health: A case study of shallow water wells and boreholes in three major communities in Northern Cross-River,Southern Nigeria

The quality of water sources and its potential health implications to adults and children populations of respective major communities in Northern Cross-River was assessed. Water samples (n = 10/water source/site) were collected from three (Okpoma, Okuku and Ugaga) communities and heavy metal concentrations (Lead (Pb), Cadmium (Cd), Chromium (Cr), Manganese (Mn), Nickel (Ni), Copper (Cu), Cobalt (Co), and Zinc (Zn)) were evaluated using Atomic Absorption Spectrometer (AAS). Overall, Pb, Cd, Ni, and Co were higher than drinking water guidelines, while only Cr, Mn, Cu, and Zn were within the permissible limits. The estimated average daily intake (EADI) and target hazard quotient (THQ) were used to determine risk implications for adult and children consumer populations. The EADI for Pb in adults for borehole water, Pb and Cr by child consumer population for borehole and shallow well water exceeded the reference dose (RfD) by USEPA. The THQ for adult population were >1 for Pb in borehole water and >1 for Pb and Cr across all sites for the child consumer population. Overall, our findings indicate toxicity and higher hazard risk for both adult (Pb) and children (Pb and Cr) populations that source drinking water from borehole and shallow well water in these communities.     

Spatial Access to Emergency Services in Low- and Middle-Income Countries: A GIS-Based Analysis

Injury is a leading cause of the global disease burden, accounting for 10 percent of all deaths worldwide. Despite 90 percent of these deaths occurring in low and middle-income countries (LMICs), the majority of trauma research and infrastructure development has taken place in high-income settings. Furthermore, although accessible services are of central importance to a mature trauma system, there remains a paucity of literature describing the spatial accessibility of emergency services in LMICs. Using data from the Service Provision Assessment component of the Demographic and Health Surveys of Namibia and Haiti we defined the capabilities of healthcare facilities in each country in terms of their preparedness to provide emergency services. A Geographic Information System-based network analysis method was used to define 5- 10- and 50-kilometer catchment areas for all facilities capable of providing 24-hour care, higher-level resuscitative services or tertiary care. The proportion of a country’s population with access to each level of service was obtained by amalgamating the catchment areas with a population layer. A significant proportion of the population of both countries had poor spatial access to lower level services with 25% of the population of Haiti and 51% of the population of Namibia living further than 50 kilometers from a facility capable of providing 24-hour care. Spatial access to tertiary care was considerably lower with 51% of Haitians and 72% of Namibians having no access to these higher-level services within 50 kilometers. These results demonstrate a significant disparity in potential spatial access to emergency services in two LMICs compared to analogous estimates from high-income settings, and suggest that strengthening the capabilities of existing facilities may improve the equity of emergency services in these countries. Routine collection of georeferenced patient and facility data in LMICs will be important to understanding how spatial access to services influences outcomes.     

Cultural Importance Indices: A Comparative Analysis Based on the Useful Wild Plants of Southern Cantabria (Northern Spain)<Superscript>1</Superscript>

Cultural Importance Indices: A Comparative Analysis Based on the Useful Wild Plants of Southern Cantabria (Northern Spain). This paper compares four indices based on informant consensus. Each index aims to assess the cultural significance of plant species and is suitable for statistical testing of different hypotheses. For the comparison, we used data concerning plants traditionally used in the Campoo area of southern Cantabria in northern Spain. Our results show a positive and significant correlation between the number of uses (NU) and the frequency of citation (FC) of the species. It seems to be a general rule that the more versatile a plant, the more widespread its usefulness. In addition, NU is highly influenced by the number of use-categories in the study. Consequently, an objective index must rely on FC more than NU. We propose the use of the cultural importance index (CI), which is defined as the summation of the informants’ proportions that mention each of the uses of the species. The CI index is highly correlated with FC and, although it also considers diversity of use, each use-category is conveniently weighted by the number of informants mentioning it. Despite the use of cultural significance indices being questioned, we believe that indices based on in-depth, semi-structured interviews are still very useful for compilation studies of passive knowledge, such as most ethnobotanical works conducted in the last three decades in Europe.     

Gene pool differences between Northern and Southern Altaians inferred from the data on Y-chromosomal haplogroups

Y-chromosomal haplogroups composition and frequencies were analyzed in Northern and Southern Altaians. In the gene pool of Altaians a total of 18 Y-chromosomal haplogroups were identified, including C3xM77, C3c, DxM15, E, F^*, J2, I1a, I1b, K^*, N^*, N2, N3a, O3, P^*, Q^*, R1^*, R1a1, and R1b3. The structuring nature of the Altaic gene pool is determined by the presence of the Caucasoid and Mongoloid components, along with the ancient genetic substratum, marked by the corresponding Western and Eastern Eurasian haplogroups. Haplogroup R1a1 prevailed in both ethnic groups, accounting for about 53 and 38% of paternal lineages in Southern and Northern Altaians, respectively. This haplogroup is thought to be associated with the eastward expansion of early Indo-Europeans, and marks Caucasoid element in the gene pools of South Siberian populations. Similarly to haplogroup K^*, the second frequent haplogroup Q^* represents paleo-Asiatic marker, probably associated with the Ket and Samoyedic contributions to the Altaic gene pool. The presence of lineages N2 and N3a can be explained as the contribution of Finno-Ugric tribes, assimilated by ancient Turks. The presence of haplogroups C3xM77, C3c, N^*, and O3 reflects the contribution of Central Asian Mongoloid groups. These haplogroups, probably, mark the latest movements of Mongolian migrants from the territory of contemporary Tuva and Mongolia. The data of factor analysis, variance analysis, cluster analysis, and phylogenetic analysis point to substantial genetic differentiation of Northern and Southern Altaians. The differences between Northern and Southern Altaians in the haplogroup composition, as well as in the internal haplotype structure were demonstrated.     

Season of Birth and Morningness: Comparison Between the Northern and Southern Hemispheres

The present study explored the possible role of the photoperiod at birth on morningness by collecting data in the northern (Italy) and southern (Australia) hemispheres. To assess circadian typology, the Composite Scale of Morningness (CS) was administered to a sample of 1734 university students (977 Italian and 757 Australian; 1099 females and 635 males; age 24.79?±?7.45 yrs [mean?±?SD]). Consistent with the literature, females reported higher CS scores (morningness) than males, and Australian participants reported higher CS scores than Italian participants. Allowing for the fact the seasons are reversed between the hemispheres, the results are in line with previous studies. The authors found more evening types were born during the seasons associated with longer photoperiod (spring and summer), and more morning types were born during the seasons associated with shorter photoperiod (autumn and winter), indirectly supporting an imprinting-like phenomenon played by the photoperiod at birth. (Author correspondence: vincenzo.natale@.unibo.it)     

Economic Appraisal of Ontario's Universal Influenza Immunization Program: A Cost-Utility Analysis

Background

In July 2000, the province of Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free seasonal influenza vaccines for the entire population. This is the first large-scale program of its kind worldwide. The objective of this study was to conduct an economic appraisal of Ontario''s UIIP compared to a targeted influenza immunization program (TIIP).

Methods and Findings

A cost-utility analysis using Ontario health administrative data was performed. The study was informed by a companion ecological study comparing physician visits, emergency department visits, hospitalizations, and deaths between 1997 and 2004 in Ontario and nine other Canadian provinces offering targeted immunization programs. The relative change estimates from pre-2000 to post-2000 as observed in other provinces were applied to pre-UIIP Ontario event rates to calculate the expected number of events had Ontario continued to offer targeted immunization. Main outcome measures were quality-adjusted life years (QALYs), costs in 2006 Canadian dollars, and incremental cost-utility ratios (incremental cost per QALY gained). Program and other costs were drawn from Ontario sources. Utility weights were obtained from the literature. The incremental cost of the program per QALY gained was calculated from the health care payer perspective. Ontario''s UIIP costs approximately twice as much as a targeted program but reduces influenza cases by 61% and mortality by 28%, saving an estimated 1,134 QALYs per season overall. Reducing influenza cases decreases health care services cost by 52%. Most cost savings can be attributed to hospitalizations avoided. The incremental cost-effectiveness ratio is Can$10,797/QALY gained. Results are most sensitive to immunization cost and number of deaths averted.

Conclusions

Universal immunization against seasonal influenza was estimated to be an economically attractive intervention. Please see later in the article for the Editors'' Summary     

A Century of Tuberculosis Epidemiology in the Northern and Southern Hemisphere: The Differential Impact of Control Interventions

Background

Cape Town has one of the highest TB burdens of any city in the world. In 1900 the City of Cape Town, New York City and London had high mortality of tuberculosis (TB). Throughout the 20th century contemporaneous public health measures including screening, diagnosis and treatment were implemented in all three settings. Mandatory notification of TB and vital status enabled comparison of disease burden trajectories.

Methods

TB mortality, notification and case fatality rates were calculated from 1912 to 2012 using annual TB notifications, TB death certifications and population estimates. Notification rates were stratified by age and in Cape Town by HIV status (from 2009 onwards).

Results

Pre-chemotherapy, TB mortality and notification rates declined steadily in New York and London but remained high in Cape Town. Following introduction of combination chemotherapy, mean annual case fatality dropped from 45–60% to below 10% in all three settings. Mortality and notification rates subsequently declined, although Cape Town notifications did not decline as far as those in New York or London and returned to pre-chemotherapy levels by 1980. The proportional contribution of childhood TB diminished in New York and London but remained high in Cape Town. The advent of the Cape Town HIV-epidemic in the 1990s was associated with a further two-fold increase in incidence. In 2012, notification rates among HIV-negatives remained at pre-chemotherapy levels.

Conclusions

TB control was achieved in New York and London but failed in Cape Town. The TB disease burden trajectories started diverging before the availability of combination chemotherapy in 1952 and further diverged following the HIV epidemic in 1990. Chemotherapy impacted case fatality but not transmission, evidenced by on-going high childhood TB rates. Currently endemic TB results from high on-going transmission, which has been exacerbated by the HIV epidemic. TB control will require reducing transmission, which is inexorably linked to prevailing socio-economic factors.