Human resources for health at the district level in Indonesia: the smoke and mirrors of decentralization

<p>Abstract</p> <p>Background</p> <p>In 2001 Indonesia embarked on a rapid decentralization of government finances and functions to district governments. One of the results is that government has less information about its most valuable resource, the people who provide the services. The objective of the work reported here is to determine the stock of human resources for health in 15 districts, their service status and primary place of work. It also assesses the effect of decentralization on management of human resources and the implications for the future.</p> <p>Methods</p> <p>We enumerated all health care providers (doctors, nurses and midwives), including information on their employment status and primary place of work, in each of 15 districts in Java. Data were collected by three teams, one for each province.</p> <p>Results</p> <p>Provider density (number of doctors, nurses and midwives/1000 population) was low by international standards – 11 out of 15 districts had provider densities less than 1.0. Approximately half of all three professional groups were permanent public servants. Contractual employment was also important for both nurses and midwives. The private sector as the primary source of employment is most important for doctors (37% overall) and increasingly so for midwives (10%). For those employed in the public sector, two-thirds of doctors and nurses work in health centres, while most midwives are located at village-level health facilities.</p> <p>Conclusion</p> <p>In the health system established after Independence, the facilities established were staffed through a period of obligatory service for all new graduates in medicine, nursing and midwifery. The last elements of that staffing system ended in 2007 and the government has not been able to replace it. The private sector is expanding and, despite the fact that it will be of increasing importance in the coming decades, government information about providers in private practice is decreasing. Despite the promise of decentralization to increase sectoral "decision space" at the district level, the central government now has control over essentially all public sector health staff at the district level, marking a return to the situation of 20 years ago. At the same time, Indonesia has changed dramatically. The challenge now is to envision a new health system that takes account of these changes. Envisioning the new system is a crucial first step for development of a human resources policy which, in turn, will require more information about health care providers, public and private, and increased capacity for human resource planning.</p

Using sparse categorical principal components to estimate asset indices: new methods with an application to rural southeast asia

PRIFPRI3; DCA; ISI; 4 Transforming Agricultural and Rural EconomiesDSG

A mediation approach to understanding socio-economic inequalities in maternal health-seeking behaviours in Egypt.

BACKGROUND: The levels and origins of socio-economic inequalities in health-seeking behaviours in Egypt are poorly understood. This paper assesses the levels of health-seeking behaviours related to maternal care (antenatal care [ANC] and facility delivery) and their accumulation during pregnancy and childbirth. Secondly, it explores the mechanisms underlying the association between socio-economic position (SEP) and maternal health-seeking behaviours. Thirdly, it examines the effectiveness of targeting of free public ANC and delivery care. METHODS: Data from the 2008 Demographic and Health Survey were used to capture two latent constructs of SEP: individual socio-cultural capital and household-level economic capital. These variables were entered into an adjusted mediation model, predicting twelve dimensions of maternal health-seeking; including any ANC, private ANC, first ANC visit in first trimester, regular ANC (four or more visits during pregnancy), facility delivery, and private delivery. ANC and delivery care costs were examined separately by provider type (public or private). RESULTS: While 74.2% of women with a birth in the 5-year recall period obtained any ANC and 72.4% delivered in a facility, only 48.8% obtained the complete maternal care package (timely and regular facility-based ANC as well as facility delivery) for their most recent live birth. Both socio-cultural capital and economic capital were independently positively associated with receiving any ANC and delivering in a facility. The strongest direct effect of socio-cultural capital was seen in models predicting private provider use of both ANC and delivery. Despite substantial proportions of women using public providers reporting receipt of free care (ANC: 38%, delivery: 24%), this free-of-charge public care was not effectively targeted to women with lowest economic resources. CONCLUSIONS: Socio-cultural capital is the primary mechanism leading to inequalities in maternal health-seeking in Egypt. Future studies should therefore examine the objective and perceived quality of care from different types of providers. Improvements in the targeting of free public care could help reduce the existing SEP-based inequalities in maternal care coverage in the short term

Error sources and data limitations for the prediction ofsurface gravity: a case study using benchmarks

Gravity-based heights require gravity values at levelled benchmarks (BMs), whichsometimes have to be predicted from surrounding observations. We use EGM2008 andthe Australian National Gravity Database (ANGD) as examples of model and terrestrialobserved data respectively to predict gravity at Australian national levelling network(ANLN) BMs. The aim is to quantify errors that may propagate into the predicted BMgravity values and then into gravimetric height corrections (HCs). Our results indicatethat an approximate ±1 arc-minute horizontal position error of the BMs causesmaximum errors in EGM2008 BM gravity of ~ 22 mGal (~55 mm in the HC at ~2200 melevation) and ~18 mGal for ANGD BM gravity because the values are not computed atthe true location of the BM. We use RTM (residual terrain modelling) techniques toshow that ~50% of EGM2008 BM gravity error in a moderately mountainous regioncan be accounted for by signal omission. Non-representative sampling of ANGDgravity in this region may cause errors of up to 50 mGals (~120 mm for the Helmertorthometric correction at ~2200 m elevation). For modelled gravity at BMs to beviable, levelling networks need horizontal BM positions accurate to a few metres, whileRTM techniques can be used to reduce signal omission error. Unrepresentative gravitysampling in mountains can be remedied by denser and more representative re-surveys,and/or gravity can be forward modelled into regions of sparser gravity

Phylogenetic relationships of cone snails endemic to Cabo Verde based on mitochondrial genomes

Background: Due to their great species and ecological diversity as well as their capacity to produce hundreds of different toxins, cone snails are of interest to evolutionary biologists, pharmacologists and amateur naturalists alike. Taxonomic identification of cone snails still relies mostly on the shape, color, and banding patterns of the shell. However, these phenotypic traits are prone to homoplasy. Therefore, the consistent use of genetic data for species delimitation and phylogenetic inference in this apparently hyperdiverse group is largely wanting. Here, we reconstruct the phylogeny of the cones endemic to Cabo Verde archipelago, a well-known radiation of the group, using mitochondrial (mt) genomes. Results: The reconstructed phylogeny grouped the analyzed species into two main clades, one including Kalloconus from West Africa sister to Trovaoconus from Cabo Verde and the other with a paraphyletic Lautoconus due to the sister group relationship of Africonus from Cabo Verde and Lautoconus ventricosus from Mediterranean Sea and neighboring Atlantic Ocean to the exclusion of Lautoconus endemic to Senegal (plus Lautoconus guanche from Mauritania, Morocco, and Canary Islands). Within Trovaoconus, up to three main lineages could be distinguished. The clade of Africonus included four main lineages (named I to IV), each further subdivided into two monophyletic groups. The reconstructed phylogeny allowed inferring the evolution of the radula in the studied lineages as well as biogeographic patterns. The number of cone species endemic to Cabo Verde was revised under the light of sequence divergence data and the inferred phylogenetic relationships. Conclusions: The sequence divergence between continental members of the genus Kalloconus and island endemics ascribed to the genus Trovaoconus is low, prompting for synonymization of the latter. The genus Lautoconus is paraphyletic. Lautoconus ventricosus is the closest living sister group of genus Africonus. Diversification of Africonus was in allopatry due to the direct development nature of their larvae and mainly triggered by eustatic sea level changes during the Miocene-Pliocene. Our study confirms the diversity of cone endemic to Cabo Verde but significantly reduces the number of valid species. Applying a sequence divergence threshold, the number of valid species within the sampled Africonus is reduced to half.Spanish Ministry of Science and Innovation [CGL2013-45211-C2-2-P, CGL2016-75255-C2-1-P, BES-2011-051469, BES-2014-069575, Doctorado Nacional-567]info:eu-repo/semantics/publishedVersio

Small farmers, NGOs, and a Walmart World: Welfare effects of supermarkets operating in Nicaragua

Despite more than a decade of NGO and government activities promoting developing world farmer participation in high-value agricultural markets, evidence regarding the household welfare effects of such initiatives is limited. This paper analyzes the geographic placement of supermarket supply chains in Nicaragua between 2000 and 2008 and uses a difference-in-difference specification on measures of supplier and non-supplier assets to estimate the welfare effects of small farmer participation. Though results indicate that selling to supermarkets increases household productive asset holdings, they also suggest that only farmers with advantageous endowments of geography and water are likely to participate

Is equal access to higher education in South Asia and sub-Saharan Africa achievable by 2030?

Higher education is back in the spotlight, with post-2015 sustainable development goals emphasising equality of access. In this paper, we highlight the long distance still to travel to achieve the goal of equal access to higher education for all, with a focus on poorer countries which tend to have lower levels of enrolment in higher education. Analysing Demographic and Health Survey data from 35 low- and middle-income countries in sub-Saharan Africa and South Asia, we show wide wealth inequalities in particular, with few if any of the poorest gaining access to higher education in some countries. We further identify that wealth and gender inequalities interact and tend to be wider in countries where levels of higher education are higher. This implies that expansion in access to higher education may predominantly benefit the rich, unless measures are taken to tackle inequalities. We find that that the rates of increase necessary for the attainment of the equal access goal by 2030 are particularly high. They pose a particularly difficult challenge given the access inequalities present from primary and secondary education in a wide majority of countries in our analysis. We therefore suggest that any measures aimed at attaining the goal need to tackle inequalities in access within a system-wide approach, focusing on the level of education at which inequalities initially manifest, alongside higher education.This is the final version of the article. It first appeared from Springer via http://dx.doi.org/10.1007/s10734-016-0039-

Interactions and potential implications of Plasmodium falciparum-hookworm coinfection in different age groups in south-central Côte d'Ivoire

BACKGROUND: Given the widespread distribution of Plasmodium and helminth infections, and similarities of ecological requirements for disease transmission, coinfection is a common phenomenon in sub-Saharan Africa and elsewhere in the tropics. Interactions of Plasmodium falciparum and soil-transmitted helminths, including immunological responses and clinical outcomes of the host, need further scientific inquiry. Understanding the complex interactions between these parasitic infections is of public health relevance considering that control measures targeting malaria and helminthiases are going to scale.METHODOLOGY: A cross-sectional survey was carried out in April 2010 in infants, young school-aged children, and young non-pregnant women in south-central Côte d'Ivoire. Stool, urine, and blood samples were collected and subjected to standardized, quality-controlled methods. Soil-transmitted helminth infections were identified and quantified in stool. Finger-prick blood samples were used to determine Plasmodium spp. infection, parasitemia, and hemoglobin concentrations. Iron, vitamin A, riboflavin, and inflammation status were measured in venous blood samples.PRINCIPAL FINDINGS: Multivariate regression analysis revealed specific association between infection and demographic, socioeconomic, host inflammatory and nutritional factors. Non-pregnant women infected with P. falciparum had significantly lower odds of hookworm infection, whilst a significant positive association was found between both parasitic infections in 6- to 8-year-old children. Coinfected children had lower odds of anemia and iron deficiency than their counterparts infected with P. falciparum alone.CONCLUSIONS/SIGNIFICANCE: Our findings suggest that interaction between P. falciparum and light-intensity hookworm infections vary with age and, in school-aged children, may benefit the host through preventing iron deficiency anemia. This observation warrants additional investigation to elucidate the mechanisms and consequences of coinfections, as this information could have important implications when implementing integrated control measures against malaria and helminthiases

Socioeconomic Inequalities in Childhood Undernutrition in India: Analyzing Trends between 1992 and 2005

India experienced a rapid economic boom between 1991 and 2007. However, this economic growth has not translated into improved nutritional status among young Indian children. Additionally, no study has assessed the trends in social disparities in childhood undernutrition in the Indian context. We examined the trends in social disparities in underweight and stunting among Indian children aged less than three years using nationally representative data.We analyzed data from the three cross-sectional rounds of National Family Health Survey of India from 1992, 1998 and 2005. The social factors of interest were: household wealth, maternal education, caste, and urban residence. Using multilevel modeling to account for the nested structure and clustering of data, we fit multivariable logistic regression models to quantify the association between the social factors and the binary outcome variables. The final models additionally included age, gender, birth order of child, religion, and age of mother. We analyzed the trend by testing for interaction of the social factor and survey year in a dataset pooled from all three surveys.While the overall prevalence rates of undernutrition among Indian children less than three decreased over the 1992-2005 period, social disparities in undernutrition over these 14 years either widened or stayed the same. The absolute rates of undernutrition decreased for everyone regardless of their social status. The disparities by household wealth were greater than the disparities by maternal education. There were no disparities in undernutrition by caste, gender or rural residence.There was a steady decrease in the rates of stunting in the 1992-2005 period, while the decline in underweight was greater between 1992 and 1998 than between 1998 and 2005. Social disparities in childhood undernutrition in India either widened or stayed the same during a time of major economic growth. While the advantages of economic growth might be reaching everyone, children from better-off households, with better educated mothers appear to have benefited to a greater extent than less privileged children. The high rates of undernutrition (even among the socially advantaged groups) and the persistent social disparities need to be addressed in an urgent and comprehensive manner