Comparing the CarbonTracker and M5-4DVar data assimilation systems for CO2 surface flux inversions

Data assimilation systems allow for estimating surface fluxes of greenhouse gases from atmospheric concentration measurements. Good knowledge about fluxes is essential to understand how climate change affects ecosystems and to characterize feedback mechanisms. Based on the assimilation of more than 1 year of atmospheric in situ concentration measurements, we compare the performance of two established data assimilation models, CarbonTracker and TM5-4DVar (Transport Model 5 - Four-Dimensional Variational model), for CO2 flux estimation. CarbonTracker uses an ensemble Kalman filter method to optimize fluxes on ecoregions. TM5-4DVar employs a 4-D variational method and optimizes fluxes on a 6° x 4° longitude-latitude grid. Harmonizing the input data allows for analyzing the strengths and weaknesses of the two approaches by direct comparison of the modeled concentrations and the estimated fluxes. We further assess the sensitivity of the two approaches to the density of observations and operational parameters such as the length of the assimilation time window. Our results show that both models provide optimized CO2 concentration fields of similar quality. In Antarctica CarbonTracker underestimates the wintertime CO2 concentrations, since its 5-week assimilation window does not allow for adjusting the distant surface fluxes in response to the detected concentration mismatch. Flux estimates by CarbonTracker and TM5-4DVar are consistent and robust for regions with good observation coverage, regions with low observation coverage reveal significant differences. In South America, the fluxes estimated by TM5-4DVar suffer from limited representativeness of the few observations. For the North American continent, mimicking the historical increase of the measurement network density shows improving agreement between CarbonTracker and TM5-4DVar flux estimates for increasing observation density. © Author(s) 2015

Catastrophic total costs in tuberculosis-affected households and their determinants since Indonesia's implementation of universal health coverage

Background: As well as imposing an economic burden on affected households, the high costs related to tuberculosis (TB) can create access and adherence barriers. This highlights the particular urgency of achieving one of the End TB Strategy's targets: that no TB-affected households have to face catastrophic costs by 2020. In Indonesia, as elsewhere, there is also an emerging need to provide social protection by implementing universal health coverage (UHC). We therefore assessed the incidence of catastrophic total costs due to TB, and their determinants since the implementation of UHC. Methods: We interviewed adult TB and multidrug-resistant TB (MDR-TB) patients in urban, suburban and rural areas of Indonesia who had been treated for at least one month or had finished treatment no more than one month earlier. Following the WHO recommendation, we assessed the incidence of catastrophic total costs due to TB. We also analyzed the sensitivity of incidence relative to several thresholds, and measured differences between poor and non-poor households in the incidence of catastrophic costs. Generalized linear mixed-model analysis was used to identify determinants of the catastrophic total costs. Results: We analyzed 282 TB and 64 MDR-TB patients. For TB-related services, the median (interquartile range) of total costs incurred by households was 133 USD (55-576); for MDR-TB-related services, it was 2804 USD (1008-4325). The incidence of catastrophic total costs in all TB-affected households was 36% (43% in poor households and 25% in non-poor households). For MDR-TB-affected households, the incidence was 83% (83% and 83%). In TB-affected households, the determinants of catastrophic total costs were poor households (adjusted odds ratio [aOR]=3.7, 95% confidence interval [CI]: 1.7-7.8); being a breadwinner (aOR=2.9, 95% CI: 1.3-6.6); job loss (aOR=21.2; 95% CI

Catastrophic costs due to tuberculosis worsen treatment outcomes: a prospective cohort study in Indonesia

BACKGROUND: While the incidence of catastrophic costs due to tuberculosis (TB) remains high, there is little evidence about their impact on TB treatment outcomes and adherence. We assessed their effect on treatment outcomes and adherence in Indonesia. METHODS: We interviewed 282 adult TB patients who underwent TB treatment in urban, suburban and rural districts of Indonesia. One year after the interview, we followed up treatment adherence and outcomes. We applied multivariable analysis using generalized linear mixed models. RESULTS: Follow-up was complete for 252/282 patients. Eighteen (7%) patients had unsuccessful treatment and 40 (16%) had poor adherence. At a threshold of 30% of annual household income, catastrophic costs negatively impacted treatment outcomes (adjusted odds ratio [aOR] 4.15 [95% confidence interval {CI} 1.15 to 15.01]). At other thresholds, the associations showed a similar pattern but were not statistically significant. The association between catastrophic costs and treatment adherence is complex because of reverse causation. After adjustment, catastrophic costs negatively affected treatment adherence at the 10% and 15% thresholds (aOR 2.11 [95% CI 0.97 to 4.59], p = 0.059 and aOR 2.06 [95% CI 0.95 to 4.46], p = 0.07). There was no evidence of such an effect at other thresholds. CONCLUSIONS: Catastrophic costs negatively affect TB treatment outcomes and treatment adherence. To eliminate TB, it is essential to mitigate catastrophic costs

Cost of seeking care for tuberculosis since the implementation of universal health coverage in Indonesia

Background: Although tuberculosis (TB) patients often incur high costs to access TB-related services, it was unclear beforehand whether the implementation of universal health coverage (UHC) in Indonesia in 2014 would reduce direct costs and change the pattern of care-seeking behaviour. After its introduction, we therefore assessed TB patients' care-seeking behaviour and the costs they incurred for diagnosis, and the determinants of both. Methods: In this cross sectional study, we interviewed adult TB patients in urban, suburban, and rural districts of Indonesia in July-September 2016. We selected consecutively patients who had been treated for TB in primary health centers for at least 1 month until we reached at least 90 patients in each district. After establishing which direct and indirect costs they had incurred during the pre-diagnostic phase, we calculated the total costs (in US Dollars). To identify the determinants of these costs, we applied a general linear mixed model to adjust for our cluster-sampling design. Results: Ninety-three patients of the 282 included in our analysis (33%) first sought care at a private clinic. The preference for such clinics was higher among those living in the rural district (aOR 1.88, 95% CI 0.85-4.15, P = 0.119) and among those with a low educational level (aOR 1.69, 95% CI 0.92-3.10, P = 0.090). Visiting a private clinic as the first contact also led to more visits (β 0.90, 95% CI 0.57-1.24, P < 0.001) and higher costs than first visiting a Primary Health Centre, both in terms of direct costs (β = 16.87, 95%CI 10.54-23.20, P < 0.001) and total costs (β = 18.41, 95%CI 10.35-26.47, P < 0.001). Conclusion: Despite UHC, high costs of TB seeking care remain, with direct medical costs contributing most to the total costs. First seeking care from private providers tends to lead to more pre-diagnostic visits and higher costs. To reduce diagnostic delays and minimize patients' costs, it is essential to strengthen the public-private mix and reduce the fragmented system between the national health insurance scheme and the National TB Programme

Associations between community health workers' home visits and education-based inequalities in institutional delivery and perinatal mortality in rural Uttar Pradesh, India: a cross-sectional study

INTRODUCTION: India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to visit and counsel women before and after birth. Little is known about the extent to which exposure to ASHAs' home visits has reduced perinatal health inequalities as intended. This study aimed to examine whether ASHAs' third trimester home visits may have contributed to equitable improvements in institutional delivery and reductions in perinatal mortality rates (PMRs) between women with varying education levels in Uttar Pradesh (UP) state, India. METHODS: Cross-sectional survey data were collected from a representative sample of 52 615 women who gave birth in the preceding 2 months in rural areas of 25 districts of UP in 2014-2015. We analysed the data using generalised linear modelling to examine the associations between exposure to home visits and education-based inequalities in institutional delivery and PMRs. RESULTS: Third trimester home visits were associated with higher institutional delivery rates, in particular public facility delivery rates (adjusted risk ratio (aRR) 1.32, 95% CI 1.30 to 1.34), and to a lesser extent private facility delivery rates (aRR 1.09, 95% CI 1.04 to 1.13), after adjusting for confounders. Associations were stronger among women with lower education levels. Having no compared with any third trimester home visits was associated with higher perinatal mortality (aRR 1.18, 95% CI 1.09 to 1.28). Having any versus no visits was more highly associated with lower perinatal mortality among women with lower education levels than those with the most education, and most notably among public facility births. CONCLUSIONS: The results suggest that ASHAs' home visits in the third trimester contributed to equitable improvements in institutional deliveries and lower PMRs, particularly within the public sector. Broader strategies must reinforce the role of ASHAs' home visits in reaching the sustainable development goals of improving maternal and newborn health and leaving no one behind

Measuring health inequality among children in developing countries: does the choice of the indicator of economic status matter?

Background Currently, poor-rich inequalities in health in developing countries receive a lot of attention from both researchers and policy makers. Since measuring economic status in developing countries is often problematic, different indicators of wealth are used in different studies. Until now, there is a lack of evidence on the extent to which the use of different measures of economic status affects the observed magnitude of health inequalities. Methods This paper provides this empirical evidence for 10 developing countries, using the Demographic and Health Surveys data-set. We compared the World Bank asset index to three alternative wealth indices, all based on household assets. Under-5 mortality and measles immunisation coverage were the health outcomes studied. Poor-rich inequalities in under-5 mortality and measles immunisation coverage were measured using the Relative Index of Inequality. Results Comparing the World Bank index to the alternative indices, we found that (1) the relative position of households in the national wealth hierarchy varied to an important extent with the asset index used, (2) observed poor-rich inequalities in under-5 mortality and immunisation coverage often changed, in some cases to an important extent, and that (3) the size and direction of this change varied per country, index, and health indicator. Conclusion Researchers and policy makers should be aware that the choice of the measure of economic status influences the observed magnitude of health inequalities, and that differences in health inequalities between countries or time periods, may be an artefact of different wealth measures used