Studying complex interventions : reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco

Peer reviewedPublisher PD

Sea state and rain: a second take on dual-frequency altimetry

TOPEX and Jason were the first two dual-frequency altimeters in space, with both operating at Ku- and C-band. Each thus gives two measurements of the normalized backscatter, sigma0, (from which wind speed is calculated) and two estimates of wave height. Departures from a well-defined relationship between the Ku- and C-band sigma0 values give an indication of rain.This paper investigates differences between the two instruments using data from Jason's verification phase. Jason's Ku-band estimates of wave height are ~1.8% less than TOPEX's, whereas its sigma0 values are higher. When these effects have been removed the root mean square (r.m.s.) mismatch between TOPEX and Jason's Ku-band observations is close to that for TOPEX's observations at its two frequencies, and the changes in sigma0 with varying wave height conditions are the same for the two altimeters. Rain flagging and quantitative estimates of rain rate are both based on the atmospheric attenuation derived from the sigma0 measurements at the two frequencies. The attenuation estimates of TOPEX and Jason agree very well, and a threshold of -0.5 dB is effective at removing the majority of spurious data records from the Jason GDRs. In the high sigma0 regime, anomalous data can be cause by processes other than rain. Consequently, for these low wind conditions, neither can reliable rain detection be based on altimetry alone, nor can a generic rain flag be expected to remove all suspect data

Performance-based financing as a health system reform : mapping the key dimensions for monitoring and evaluation

Peer reviewedPublisher PD

Working practices and incomes of health workers : evidence from an evaluation of a delivery fee exemption scheme in Ghana

Background: This article describes a survey of health workers and traditional birth attendants (TBAs) which was carried out in 2005 in two regions of Ghana. The objective of the survey was to ascertain the impact of the introduction of a delivery fee exemption scheme on both health workers and those providers who were excluded from the scheme (TBAs). This formed part of an overall evaluation of the delivery fee exemption scheme. The results shed light not only on the scheme itself but also on the general productivity of a range of health workers in Ghana. Methods: A structured questionnaire was developed, covering individual and household characteristics, working hours and practices, sources of income, and views of the exemptions scheme and general motivation. After field testing, this was administered to 374 respondents in 12 districts of Central and Volta regions. The respondents included doctors, medical assistants (MAs), public and private midwives, nurses, community health nurses (CHNs), and traditional birth attendants, both trained and untrained. Results: Health workers were well informed about the delivery fee exemptions scheme and their responses on its impact suggest a realistic view that it was a good scheme, but one that faces serious challenges regarding financial sustainability. Concerning its impact on their morale and working conditions, the responses were broadly neutral. Most public sector workers have seen an increased workload, but counterbalanced by increased pay. TBAs have suffered, in terms of client numbers and income, while the picture for private midwives is mixed. The survey also sheds light on pay and productivity. The respondents report long working hours, with a mean of 54 hours per week for community nurses and up to 129 hours per week for MAs. Weekly reported client loads in the public sector range from a mean of 86 for nurses to 269 for doctors. Over the past two years, reported working hours have been increasing, but so have pay and allowances (for doctors, allowances now make up 66% of their total pay). The lowest paid public health worker now earns almost ten times the average gross national income (GNI) per capita, while the doctors earn 38.5 times GNI per capita. This compares well with average government pay of four times GNI per capita. Comparing pay with outputs, the relatively high number of clients reported by doctors reduces their pay differential, so that the cost per client – $1.09 – is similar to a nurse's (and lower than a private midwife's). Conclusion: These findings show that a scheme which increases demand for public health services while also sustaining health worker income and morale, is workable, if well managed, even within the relatively constrained human resources environment of countries like Ghana. This may be linked to the fact that internal comparisons reveal Ghana's health workers to be well paid from public sector sources.This work was undertaken as part of an international research programme – IMMPACT (Initiative for Maternal Mortality Programme Assessment) – funded by the Bill & Melinda Gates Foundation, the Department for International Development, the European Commission and USAID

The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe

Peer reviewedPublisher PD

WTO accession, the changing competitiveness of foreign-financed firms and regional development in Guangdong of southern China

This paper investigates the changing competitiveness of foreign-financed manufacturing firms and its implications for regional development in Guangdong province of southern China in the run-up to World Trade Organization (WTO) accession. It is argued that transnational corporations (TNCs) and some competitive, large-scale, locally-funded firms in Guangdong will triumph after WTO accession. The crowding-out process of small and medium sized enterprises (SMEs) in Guangdong will be accelerated in the near future, as they are competing directly with TNCs, and as their competitive advantages are diminishing, due to bureaucratic red tape and the rigorous enforcement of new government policies. Due to close business linkages with local privately-funded firms, the competitiveness and vitality of foreign-financed enterprises will have profound long term effects on the economic development of Guangdong, before and after WTO accession

Validation of the Brief Developmental Assessment in pre-school children with heart disease

INTRODUCTION: The objective of this study was to prospectively validate the “Brief Developmental Assessment”, which is a new early recognition tool for neurodevelopmental abnormalities in children with heart disease that was developed for use by cardiac teams. METHODS: This was a prospective validation study among a representative sample of 960 pre-school children with heart disease from three United Kingdom tertiary cardiac centres who were analysed grouped into five separate age bands. RESULTS: The “Brief Developmental Assessment” was successfully validated in the older four age bands, but not in the youngest representing infants under the age of 4 months, as pre-set validation thresholds were met – lower 95% confidence limit for the correlation coefficient above 0.75 – in terms of agreement of scores between two raters and with an external measure the “Mullen Scales of Early Learning”. On the basis of American Association of Pediatrics Guidelines, which state that the sensitivity and specificity of a developmental screening tool should fall between 70 and 80%, “Brief Developmental Assessment” outcome of Red meets this threshold for detection of Mullen scores >2 standard deviations below the mean. CONCLUSION: The “Brief Developmental Assessment” may be used to improve the quality of assessment of children with heart disease. This will require a training package for users and a guide to action for abnormal results. Further research is needed to determine how best to deploy the “Brief Developmental Assessment” at different time points in children with heart disease and to determine the management strategy in infants younger than 4 months old

Long-term Impact of sewage sludge application on rhizobium leguminosarum biovar trifolii: an evaluation using meta-analysis

The Long-Term Sludge Experiment (LTSE) began in 1994 at nine UK field sites as part of continuing research into the effects of sludge-borne heavy metals on soil fertility. The long-term effects of Zn, Cu, and Cd on the most probable numbers of cells (MPN) of Rhizobium leguminosarum biovar trifolii were monitored for 8 yr in sludge-amended soils. To assess the statutory limits set by the UK Sludge (Use in Agriculture) Regulations, the experimental data were reviewed using statistical methods of meta-analysis. Previous LTSE studies have focused predominantly on statistical significance rather than effect size, whereas meta-analysis focuses on the magnitude and direction of an effect, i.e., the practical significance rather than its statistical significance. Results showed Zn to be the most toxic element causing an overall significant decrease in Rhizobium MPN of −26.6% during the LTSE. The effect of Cu showed no significant effect on Rhizobium MPN at concentrations below the UK limits, although a −5% decrease in Rhizobium MPN was observed in soils where total Cu ranged from 100 to <135 mg kg−1. Overall, there was nothing to indicate that Cd had a significant effect on Rhizobium MPN below the current UK statutory limit. In summary, the UK statutory limit for Zn appears to be insufficient for protecting Rhizobium from Zn toxicity effects

Assessing Communities of Practice in health policy : A conceptual framework as a first step towards empirical research

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