Nossal Institute for Global Health - Research Publications
Now showing items 1-12 of 108
Disparities in child mortality trends: what is the evidence from disadvantaged states in India? the case of Orissa and Madhya Pradesh
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.
Harm reduction and "Clean" community: can Viet Nam have both?
The findings of our research show that while police play multiple roles in the fight against drug-related crime, they often perceived their tasks - especially preventing and controlling drug use on the one hand, and supporting harm reduction on the other - as contradictory, and this creates tensions in their work and relations with their communities. Although they are leaders and implementers of harm reduction, not all police know about it, and some remain skeptical or perceive it as contradictory to their main task of fighting drugs. Methadone treatment is seen by some as in competition with their main task of coordinating conventional drug treatment in the rehabilitation center.The history of drug use and the evolution of discourses on drug use in Viet Nam have created these conflicting pressures on police, and thus created contradictory expectations and led to different views and attitudes of police regarding various harm reduction measures. This might aid understanding why, despite the comprehensive and progressive policies on HIV/AIDS and harm reduction in Viet Nam, it is not easy for police to actively and effectively support and be involved in harm reduction at the ground level.To promote the wider acceptance of harm reduction the concept of community safety must be expanded to include community health; harm reduction must be integrated into the "new society" movement; and laws and policies need further revision to reduce contradiction between current drug laws and HIV laws.Harm reduction guidelines for police and other actors need to be disseminated and supported, embodying better ways of working between sectors, and all sectors in the partnership require support for building capacity to contribute to the overall goal.
Laos case study
(BIOMED CENTRAL LTD, 2012-07-09)
Peuan Mit is a Lao organization working to address the needs of children and youth living and working on the streets. This case study outlines how a trusted and strong relationship with local police provides mutual benefit.
Falling through the cracks: a qualitative study of HIV risks among women who use drugs and alcohol in Northeast India
UNLABELLED: BACKGROUND: HIV risks for women who inject drugs and those who engage in sex work are well documented. Women who are dependent on non-injecting drugs and alcohol are also likely to have increased vulnerability to HIV infection, but until they actually inject drugs or engage in sex work, are unlikely to come to the attention of HIV prevention programs. METHODS: We undertook a qualitative study involving nine focus group discussions (FGDs) and 27 key informant interviews to investigate the context of female drug and alcohol use in two high HIV prevalence states of India (Manipur and Nagaland) and to describe their HIV risks. The FGD and interview transcripts were thematically analyzed RESULTS: The women were relatively young (mean age 31 years in Manipur and 28 years in Nagaland), but 64% in Manipur and 35% in Nagaland were widowed or divorced. Both heroin and alcohol were commonly used by the women from Manipur, while alcohol was primarily used by the women from Nagaland, especially in the context of 'booze joints' (illicit bars). Reasons for drug and alcohol use included: to avoid symptoms of withdrawal, to suppress emotional pain, to overcome the shame of sex work, pleasure, and widowhood. HIV vulnerability was clearly described, not only in relation to injecting drug use and sex work, but also alcohol consumption. CONCLUSIONS: The contribution of alcohol use to the HIV vulnerability of women is not currently considered when HIV prevention programs are being designed and implemented leaving a group of high-risk women uncovered by much needed services such as treatment for a range of health problems including alcohol dependence.
Strategies for capacity building for health research in Bangladesh: Role of core funding and a common monitoring and evaluation framework
BACKGROUND: There is increasing interest in building the capacity of researchers in low and middle income countries (LMIC) to address their national priority health and health policy problems. However, the number and variety of partnerships and funding arrangements can create management problems for LMIC research institutes. This paper aims to identify problems faced by a health research institute in Bangladesh, describe two strategies developed to address these problems, and identify the results after three years of implementation. METHODS: This paper uses a mixture of quantitative and qualitative data collected during independent annual reviews of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) between 2006 and 2010. Quantitative data includes the number of research activities according to strategic priority areas, revenues collected and expenditure. Qualitative data includes interviews of researchers and management of ICDDR,B, and of research users and key donors. Data in a Monitoring and Evaluation Framework (MEF) were assessed against agreed indicators. RESULTS: The key problems faced by ICDDR,B in 2006 were insufficient core funds to build research capacity and supporting infrastructure, and an inability to direct research funds towards the identified research priorities in its strategic plan. Two strategies were developed to address these problems: a group of donors agreed to provide unearmarked pooled core funding, and accept a single common report based on an agreed MEF. On review after three years, there had been significant increases in total revenue, and the ability to allocate greater amounts of money on capacity building and infrastructure. The MEF demonstrated progress against strategic objectives, and better alignment of research against strategic priorities. There had also been changes in the sense of ownership and collaboration between ICDDR,B's management and its core donors. CONCLUSIONS: The changes made to funding relationships supported and monitored by an effective MEF enabled the organisation to better align funding with research priorities and to invest in capacity building. This paper identified key issues for capacity building for health research in low and middle income countries. The findings have relevance to other research institutes in similar contexts to advocate and support research capacity strengthening efforts.
Harm reduction in Cambodia: a disconnect between policy and practice
In 2003 the Government of Cambodia officially began to recognise that harm reduction was an essential approach to preventing HIV among people who use drugs and their sexual partners. Several programs aiming to control and prevent HIV among drug users have been implemented in Cambodia, mostly in the capital, Phnom Penh. However, there have been ongoing tensions between law enforcement and harm reduction actors, despite several advocacy efforts targeting law enforcement. This study attempts to better understand the implementation of harm reduction in Cambodia and how the policy environment and harm reduction program implementation has intersected with the role of law enforcement officials in Cambodia.
Taking action on the social determinants of health: improving health access for the urban poor in Mongolia
INTRODUCTION: In recent years, the country of Mongolia (population 2.8 million) has experienced rapid social changes associated with economic growth, persisting socio-economic inequities and internal migration. In order to improve health access for the urban poor, the Ministry of Health developed a "Reaching Every District" strategy (RED strategy) to deliver an integrated package of key health and social services. The aim of this article is to present findings of an assessment of the implementation of the RED strategy, and, on the basis of this assessment, articulate lessons learned for equitable urban health planning. METHODS: Principal methods for data collection and analysis included literature review, barrier analysis of health access and in-depth interviews and group discussions with health managers and providers. FINDINGS: The main barriers to health access for the urban poor relate to interacting effects of poverty, unhealthy daily living environments, social vulnerability and isolation. Implementation of the RED strategy has resulted in increased health access for the urban poor, as demonstrated by health staff having reached new clients with immunization, family planning and ante-natal care services, and increased civil registrations which enable social service provision. Organizational effects have included improved partnerships for health and increased motivation of the health workforce. Important lessons learned from the early implementation of the RED strategy include the need to form strong partnerships among stakeholders at each level of the health system and in the community, as well as the need to develop a specific financing strategy to address the needs of the very poor. The diverse social context for health in an urban poor setting calls for a decentralized planning and partnership strategy, but with central level commitment towards policy guidance and financing of pro-poor urban health strategies. CONCLUSIONS: Lessons from Mongolia mirror other international studies which point to the need to measure and take action on the social determinants of health at the local area level in order to adequately reduce persistent inequities in health care access for the urban poor.
Context-specific, evidence-based planning for scale-up of family planning services to increase progress to MDG 5: health systems research
BACKGROUND: Unmet need for family planning is responsible for 7.4 million disability-adjusted life years and 30% of the maternity-related disease burden. An estimated 35% of births are unintended and some 200 million couples state a desire to delay pregnancy or cease fertility but are not using contraception. Unmet need is higher among the poorest, lesser educated, rural residents and women under 19 years. The barriers to, and successful strategies for, satisfying all demand for modern contraceptives are heavily influenced by context. Successfully overcoming this to increase the uptake of family planning is estimated to reduce the risk of maternal death by up to 58% as well as contribute to poverty reduction, women's empowerment and educational, social and economic participation, national development and environmental protection. METHODS: To strengthen health systems for delivery of context-specific, equity-focused reproductive, maternal, newborn and child health services (RMNCH), the Investment Case study was applied in the Asia-Pacific region. Staff of local and central government and non-government organisations analysed data indicative of health service delivery through a supply-demand oriented framework to identify constraints to RMNCH scale-up. Planners developed contextualised strategies and the projected coverage increases were modelled for estimates of marginal impact on maternal mortality and costs over a five year period. RESULTS: In Indonesia, Philippines and Nepal the constraints behind incomplete coverage of family planning services included: weaknesses in commodities logistic management; geographical inaccessibility; limitations in health worker skills and numbers; legislation; and religious and cultural ideologies. Planned activities included: streamlining supply systems; establishment of Community Health Teams for integrated RMNCH services; local recruitment of staff and refresher training; task-shifting; and follow-up cards. Modelling showed varying marginal impact and costs for each setting with potential for significant reductions in the maternal mortality rate; up to 28% (25.1-30.7) over five years, costing up to a marginal USD 1.34 (1.32-1.35) per capita in the first year. CONCLUSION: Local health planners are in a prime position to devise feasible context-specific activities to overcome constraints and increase met need for family planning to accelerate progress towards MDG 5.
From reaching every district to reaching every community: analysis and response to the challenge of equity in immunization in Cambodia
(OXFORD UNIV PRESS, 2013-08-01)
BACKGROUND An international review of the Cambodian Expanded Programme on Immunization (EPI) in 2010 and other data show that despite immunization coverage increases and vaccine preventable diseases incidence reductions, inequities in access to immunization services exist. Utilizing immunization and health systems literature, analysis of global health databases and the EPI review findings, this paper examines the characteristics of immunization access and outcome inequities, and describes proposed longer-term strategic and operational responses to these problems. Findings The national programme has evolved from earlier central and provincial level planning to strengthening routine immunization coverage through the District level 'Reaching Every District Strategy'. However, despite remarkable improvements, the review found over 20% of children surveyed were not fully immunized, primarily from communities where inequities of both access and impact persist. These inequities relate mainly to socio-economic exposures including wealth and education level, population mobility and ethnicity. To address these problems, a shift in strategic and operational response is proposed that will include (a) a re-focus of planning on facility level to detect disadvantaged communities, (b) establishment of monitoring systems to provide detailed information on community access and utilization, (c) development of communication strategies and health networks that enable providers to adjust service delivery according to the needs of vulnerable populations, and (d) securing financial, management and political commitment for 'reaching every community'. CONCLUSIONS For Cambodia to achieve its immunization equity objectives and disease reduction goals, a shift of emphasis to health centre and community is needed. This approach will maximize the benefits of new vaccine introduction in the coming 'Decade of Vaccines', plus potentially extend the reach of other life-saving maternal and child health interventions to the socially disadvantaged, both in Cambodia and in other countries with a similar level of development.
The village/commune safety policy and HIV prevention efforts among key affected populations in Cambodia: finding a balance
(BIOMED CENTRAL LTD, 2012-07-09)
The Village/Commune Safety Policy was launched by the Ministry of Interior of the Kingdom of Cambodia in 2010 and, due to a priority focus on "cleaning the streets", has created difficulties for HIV prevention programs attempting to implement programs that work with key affected populations including female sex workers and people who inject drugs. The implementation of the policy has forced HIV program implementers, the UN and various government counterparts to explore and develop collaborative ways of delivering HIV prevention services within this difficult environment. The following case study explores some of these efforts and highlights the promising development of a Police Community Partnership Initiative that it is hoped will find a meaningful balance between the Village/Commune Safety Policy and HIV prevention efforts with key affected populations in Cambodia.
Meeting the needs of women who use drugs and alcohol in North-east India - a challenge for HIV prevention services
(BIOMED CENTRAL LTD, 2012-09-26)
BACKGROUND: The North-east Indian states of Manipur and Nagaland consistently report relatively high HIV prevalence. The targeted HIV prevention interventions in these two states are mostly delivered by non-government organizations (NGOs), and prevention of HIV transmission by injecting drug use is their main focus. Most injecting drug users (IDUs) are male, and the services are primarily tailored to meet their needs, which are not necessarily the same as those for women. This qualitative study describes the health service needs of women who use drugs and alcohol in Manipur and Nagaland, with the goal of identifying strategies and activities that can be implemented by NGOs wanting to improve their reach among vulnerable women. METHODS: In 2009-10, semi-structured in-depth interviews were conducted with 27 key informants and nine focus group discussions (FGDs) with women who use drugs and alcohol, and two FGDs with male IDUs. The thematic areas covered included: the context of female drug and alcohol use; drug and alcohol use patterns; HIV risk behaviours; barriers and facilitators of service use; perceived health needs; and expressed health service needs. The data were recorded, transcribed, translated and thematically analysed. RESULTS: The most problematic substance for women from Nagaland was alcohol, and for women from Manipur it was heroin. The most commonly identified health problems were primarily related to the women's drug and alcohol use, reproductive health and mental health. Other problems of major concern included social exclusion, violence, children's welfare, and financial difficulties. The expressed service needs of these women were women-only integrated health services, women-only detoxification and rehabilitation services, mental health services, desensitization of mainstream health workers, free access to medicines, assistance to meet basic needs, and a safe place for engaging in sex work. CONCLUSION: The expressed health and other service needs of women who use drugs and alcohol in Manipur and Nagaland do not match the services currently provided by HIV prevention NGOs, and this may, in part, account for the relatively poor uptake of these services by women. Strategies and activities that can be implemented by NGOs to strengthen their reach to vulnerable women are identified. However, many of these women's needs are beyond the scope of services typically offered by HIV prevention NGOs, and require a coordinated multi-sectoral response.