Nossal Institute for Global Health - Research Publications
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ItemDisparities in child mortality trends: what is the evidence from disadvantaged states in India? the case of Orissa and Madhya Pradesh(BMC, 2013-06-27)INTRODUCTION: The Millennium Development Goals prompted renewed international efforts to reduce under-five mortality and measure national progress. However, scant evidence exists about the distribution of child mortality at low sub-national levels, which in diverse and decentralized countries like India are required to inform policy-making. This study estimates changes in child mortality across a range of markers of inequalities in Orissa and Madhya Pradesh, two of India's largest, poorest, and most disadvantaged states. METHODS: Estimates of under-five and neonatal mortality rates were computed using seven datasets from three available sources--sample registration system, summary birth histories in surveys, and complete birth histories. Inequalities were gauged by comparison of mortality rates within four sub-state populations defined by the following characteristics: rural-urban location, ethnicity, wealth, and district. RESULTS: Trend estimates suggest that progress has been made in mortality rates at the state levels. However, reduction rates have been modest, particularly for neonatal mortality. Different mortality rates are observed across all the equity markers, although there is a pattern of convergence between rural and urban areas, largely due to inadequate progress in urban settings. Inter-district disparities and differences between socioeconomic groups are also evident. CONCLUSIONS: Although child mortality rates continue to decline at the national level, our evidence shows that considerable disparities persist. While progress in reducing under-five and neonatal mortality rates in urban areas appears to be levelling off, policies targeting rural populations and scheduled caste and tribe groups appear to have achieved some success in reducing mortality differentials. The results of this study thus add weight to recent government initiatives targeting these groups. Equitable progress, particularly for neonatal mortality, requires continuing efforts to strengthen health systems and overcome barriers to identify and reach vulnerable groups.
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ItemDeveloping and Costing Local Strategies to Improve Maternal and Child Health: The Investment Case Framework(PUBLIC LIBRARY SCIENCE, 2012-08)Eliana Jimenez Soto and colleagues describe the Investment Case framework, a health systems research approach for planning and budgeting, and detail the implementation of the framework in four Asian countries to improve maternal, newborn and child health.
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ItemDocumenting a long-term development model in the slums of Delhi(BIOMED CENTRAL LTD, 2016-04-28)BACKGROUND: Achieving development outcomes requires the inclusion of marginalised populations that have the least opportunity to participate in and benefit from development. Slum dwellers often see little of the 'urban advantage', suffering more from infectious diseases, increasing food costs, poor access to education and health care, inadequate water and sanitation, and informal employment. A recent Cochrane Review of the impact of slum upgrading strategies found a dearth of unbiased studies, making it difficult to draw firm conclusions. The Review calls for greater use of process data, and qualitative alongside quantitative methods of evaluation. India is a lower middle income nation with large gender disparities and around 65 million slum inhabitants. The Asha Community Health and Development Society, a non-governmental organisation based in Delhi, has delivered a multi-sectoral program across 71 slums since 1988. This article reports on a mixed-method study to document measureable health and social impacts, along with Asha's ethos and processes. METHODS: Several observational visits were made to 12 Asha slums where informal discussions were had with staff and residents (n = 50). Asha data records were analysed for change over time (and differences with greater Delhi) in selected indicators (maternal-child health, education, child sex ratio) using descriptive statistics. 34 semi-structured individual/small group interviews and 14 focus group discussions were held with staff, residents, volunteers, elected officials, civil servants, bankers, diplomats, school principals, slumlords and loan recipients (n = 147). RESULTS: Key indicators of health and social equity improved over time and compared favourably with those for greater Delhi. The Asha model emphasises rights, responsibilities, equity and non-violence. It employs strategies characterised by long-term involvement, systematic protocols and monitoring, development of civil society (especially women's and children's groups) to advocate for rights under the law, and links with foreign volunteers and fund-raisers. Stakeholders agreed that changes in community norms and living conditions were at least partly attributable to the Asha model. CONCLUSIONS: While lacking a control group or complete baseline data, evidence suggested substantial improvements in slum conditions and social equity. The Asha model offers some lessons for slum (and broader) development.
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ItemInvestment case for improving maternal and child health: results from four countries(BIOMED CENTRAL LTD, 2013-06-21)BACKGROUND: Without addressing the constraints specific to disadvantaged populations, national health policies such as universal health coverage risk increasing equity gaps. Health system constraints often have the greatest impact on disadvantaged populations, resulting in poor access to quality health services among vulnerable groups. METHODS: The Investment Cases in Indonesia, Nepal, Philippines, and the state of Orissa in India were implemented to support evidence-based sub-national planning and budgeting for equitable scale-up of quality MNCH services. The Investment Case framework combines the basic setup of strategic problem solving with a decision-support model. The analysis and identification of strategies to scale-up priority MNCH interventions is conducted by in-country planners and policymakers with facilitation from local and international research partners. RESULTS: Significant variation in scaling-up constraints, strategies, and associated costs were identified between countries and across urban and rural typologies. Community-based strategies have been considered for rural populations served predominantly by public providers, but this analysis suggests that the scaling-up of maternal, newborn, and child health services requires health system interventions focused on 'getting the basics right'. These include upgrading or building facilities, training and redistribution of staff, better supervision, and strengthening the procurement of essential commodities. Some of these strategies involve substantial early capital expenditure in remote and sparsely populated districts. These supply-side strategies are not only the 'best buys', but also the 'required buys' to ensure the quality of health services as coverage increases. By contrast, such public supply strategies may not be the 'best buys' in densely populated urbanised settings, served by a mix of public and private providers. Instead, robust regulatory and supervisory mechanisms are required to improve the accessibility and quality of services delivered by the private sector. They can lead to important maternal mortality reductions at relatively low costs. CONCLUSIONS: National strategies that do not take into consideration the special circumstances of disadvantaged areas risk disempowering local managers and may lead to a "business-as-usual" acceptance of unreachable goals. To effectively guide health service delivery at a local level, national plans should adopt typologies that reflect the different problems and strategies to scale up key MNCH interventions.