Motivating provision of high quality care: It is not all about the money

The inclusion of universal health coverage as a target in the sustainable development goal for health has boosted the global movement to improve access to healthcare services. To improve health, the services accessed must be high quality,1 yet there is mounting evidence that the quality of care delivered to populations in many low and middle income countries is inadequate.2345 Governments must consider strategies that will not only improve accessibility to care for their populations but also substantially improve quality. A priority in achieving universal health coverage is the recruitment, training, and retention of healthcare workers. However, there is widespread concern that health systems are not getting the most out of their workforce. Recent evidence shows that the quality of care provided by healthcare workers is often lower than what they are able to demonstrate in the context of a test2 or under the watchful eyes of an observer.6 The existence of such “know-do” gaps shows that substandard care cannot be fully explained by low competence or inadequate training. Low quality of care and medical errors occur more often when providers are demotivated, which can be fuelled by inadequate working conditions such as shortages of basic drugs and equipment or staff.789 Yet, although good working conditions are an important part of delivering good quality of care, they are not sufficient to ensure that health professionals are motivated and adhere to recommended treatment guidelines.1011 Here, we discuss the evidence on different approaches that can be used to increase provider motivation and ultimately improve quality of care

Perception of Neighborhood Safety and Reported Childhood Lifetime Asthma in the United States (U.S.): A Study Based on a National Survey

Recent studies have emphasized the role of psychosocial stressors as a determinant of asthma, and neighborhoods can be a potential source of such stressors. We investigated the association between parental perception of neighborhood safety and reported lifetime asthma among children.Data for the study came from the 2003-04 National Survey of Children Health (NSCH); a nationally representative cross-sectional sample of children aged 0-17 years. Demographic, socioeconomic and behavioral covariates were included in the study. Models were estimated after taking account of weighting and complex survey design. Parental report of whether the child has ever been diagnosed with asthma by a physician was used to define the outcome. Parental report of perception of neighborhood safety was the main exposure. In unadjusted models, the odds ratio (OR) for reporting asthma associated with living in neighborhoods that were perceived to be sometimes or never safe was 1.36 (95% confidence intervals [CI] 1.21, 1.53) compared to living in neighborhoods that were perceived to be always safe. Adjusting for covariates including exposure to second hand tobacco smoke, mother's self-rated health, child's physical activity and television viewing attenuated this association (OR 1.25, 95% CI 1.08, 1.43). In adjusted models, the increased odds ratio for reporting asthma was also higher among those who perceived neighborhoods as being usually safe (OR 1.15 95% CI 1.06, 1.26), as compared to always safe, suggestive of a dose-response relationship, with the differentials for usually safe and never safe being statistically significant (p = 0.009).Psychosocial stressors may be important risk factors that may impact the pathogenesis of asthma and/or contribute to asthma morbidity by triggering exacerbations through neuroimmunologic mechanisms, as well as social mechanisms

La Medicina Basada en la Evidencia: ¿mejoró la medicina que practicamos y enseñamos?

The concept of evidence-based medicine (EBM) has been increasingly incorporated in medicine practice and teaching. In the clinical arena it is defined as the use of the best available scientific evidence coming from clinical research for decision-making purposes, when facing individual patients. This paradigm change in the way medicine is taught and practiced has been due in part to the accelerated progress in scientific research, particularly in the last few decades, albeit the increasing costs involved in care of patients also played an important role in its development and consolidation. EBM involves integration of clinical expertise with the available external evidence, and provides a more critical approach to clinical problems, reducing error probabilities in different phases of the clinical process. It is not easy to reach a definitive conclusion about its impact on teaching and practice of medicine in our setting, due to the lack of systematic impact research in this area. At global level, we undoubtedly have available greater scientific evidence now, including the child health field. These scenarios, along with the amazing technological advances we are witnessing allow us to use relevant bedside clinical information. However, if we are really looking for a better medicine based on sound information but also on genuine respect to health as a basic human right, we should intensify our efforts to break once and for all with the paradigm of an authoritarian medicine, suspicious of any dissent, and reluctant to justify adequately any clinical decision made. We should additionally take advantage of the highly improved access to scientific information, and we should be willing to share such justifications with our patients in a friendly and respectful way. Similarly, we badly need to actively promote research, creativity and critical thinking at all educational levels, so we can make a real and significant contribution to the advancement of clinical medicine and public health.En los últimos años la práctica y la enseñanza médica han incorporado en forma progresiva y creciente el concepto de medicina basada en la evidencia (MBE). La misma se define como la utilización de la mejor evidencia proveniente de la investigación clínica para la toma de decisiones en el manejo del paciente individual. Esta propuesta de cambio en la manera de practicar y enseñar la medicina clínica es, en parte, consecuencia del vertiginoso avance de la investigación científica, particularmente en las últimas décadas, aunque el costo creciente involucrado en la atención de los pacientes ha jugado también un rol importante en su desarrollo y consolidación. La MBE implica la integración de la preparación y experiencia del médico con la mejor evidencia clínica externa accesible, proveniente de la investigación sistemática, proporcionando una visión más crítica en la toma de decisiones clínicas, para ofrecer atención de calidad óptima al paciente, evitando errores en cada una de las diferentes etapas del proceso de diagnóstico y tratamiento. En ausencia de información recolectada sistemáticamente, no es fácil llegar a una conclusión sobre los efectos de la MBE en la práctica y la enseñanza de la medicina en nuestro medio. Sin duda contamos hoy con mayor evidencia científica, incluyendo aquella relacionada a los problemas de salud infantil, y también se ha producido un avance vertiginoso en la tecnología que nos permite acceder a dicha información en tiempo real, a la cabecera del paciente. Sin embargo, si deseamos de veras lograr una mejor medicina, basada en la ciencia y en el respeto a la salud como un derecho que nos asiste a todos, hay necesidad de romper definitivamente con el paradigma predominante de una medicina jerárquica, poco dada a la discusión y a la justificación de las decisiones clínicas, de aprovechar la mejora sustancial ocurrida en el acceso a la evidencia disponible, y de mostrar mayor disposición a compartir amigable y respetuosamente dicha justificación con nuestros pacientes. Del mismo modo, hay la necesidad imperiosa de promover la investigación, la creatividad y el espíritu crítico en todos los niveles de la educación, para contribuir a la evidencia global que permita que la medicina clínica y la salud pública continúen avanzando

Problemática en el tratamiento tributario de la deducción de los gastos financieros que incidan conjuntamente en rentas gravadas, exoneradas e inafectas

En el presente trabajo de investigación se analiza el tratamiento tributario actual adoptado por el Tribunal Fiscal para la deducción de los gastos financieros comunes que incidan de manera conjunta en la generación de rentas gravadas, exoneradas y/o inafectas, las cuales no pueden ser atribuidas de forma directa a cada tipo de renta; estableciendo que le resulta aplicable el inciso a) del artículo 37° de la Ley del Impuesto a la Renta y no el inciso p) del artículo 21° del Reglamento de la Ley del Impuesto a la Renta. La aplicación del inciso a) del artículo 37° de la Ley para la deducción de los gastos financieros comunes - conforme al criterio adoptado por el Tribunal Fiscal - trae como consecuencia que se pueda deducir la parte proporcional de los gastos financieros comunes inherentes a las rentas exoneradas e inafectas, lo cual atenta contra el principio de causalidad, base fundamental para la deducción de los gastos, por lo que este tratamiento tributario no resulta adecuado, toda vez que, no contempla un procedimiento de prorrata y menos tiene por objetivo limitar la deducción de los gastos financieros comunes. En ese sentido, se ha planteado incorporar un límite adicional a los establecidos en el inciso a) del artículo 37° de la Ley para los casos en que se incurran en gastos por intereses y demás gastos originados por deudas que incidan de manera conjunta en rentas gravadas, exoneradas o inafectas, y no sea posible imputar de manera directa a cada tipo renta (gastos financieros comunes), a efectos de: i) prohibir la deducción de la parte proporcional destinada a la obtención de rentas exoneradas e inafectas, y así cumplir con la causalidad, principio rector de la deducción de gastos y ii) someter la parte proporcional destinada a la obtención de rentas gravadas (parte causal) a los requisitos establecidos en los numerales 1, 2 y 3 del inciso a) del artículo 37° de la Ley.The present research work analyzes the current tax treatment taken by the Tax Court for the deduction of common financial expenses that jointly affect the generation of taxed, exempted and/or unaffected income, which cannot be attributed directly to each type of income; establishing that subsection a) of article 37 of the Income Tax Law is applicable and not the subsection p) of article 21 of the Regulations of the Income Tax Law. The application of subsection a) of article 37 of the Law for the deduction of common financial expenses - in accordance with the criteria taken by the Tax Court - results in the deduction of the proportional part of the common financial expenses inherent to the income exempted and unaffected, which violates the principle of causality, fundamental basis for the deduction of expenses, so this tax treatment is not appropriate, since it does not contemplate a prorate procedure and even less has the objective of limiting the deduction of common financial expenses. In this sense, it has been proposed to incorporate an additional limit to those established in subsection a) of article 37 of the Law for cases in which expenses are incurred for interest and other expenses generated by debts that jointly affect taxed, exempted or unaffected income, and it is not possible to attribute directly to each type of income (common financial expenses), in order to: i) prohibit the deduction of the proportional part destined to obtain exempted and unaffected income, and thus accomplish with causality, the guiding principle of the deduction of expenses and ii) submit the proportional part destined to obtain taxed income (causal part) to the requirements established in numerals 1, 2 and 3 of subsection a) of article 37 of the law

Increasing access to health workers in underserved areas: a conceptual framework for measuring results.

Many countries have developed strategies to attract and retain qualified health workers in underserved areas, but there is only scarce and weak evidence on their successes or failures. It is difficult to compare lessons and measure results from the few evaluations that are available. Evaluation faces several challenges, including the heterogeneity of the terminology, the complexity of the interventions, the difficulty of assessing the influence of contextual factors, the lack of baseline information, and the need for multi-method and multi-disciplinary approaches for monitoring and evaluation. Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluating interventions for human resources for health. This paper proposes a conceptual framework that offers a model for monitoring and evaluation of retention interventions taking into account such challenges. The conceptual framework is based on a systems approach and aims to guide the thinking in evaluating an intervention to increase access to health workers in underserved areas, from its design phase through to its results. It also aims to guide the monitoring of interventions through the routine collection of a set of indicators, applicable to the specific context. It suggests that a comprehensive approach needs to be used for the design, implementation, monitoring, evaluation and review of the interventions. The framework is not intended to be prescriptive and can be applied flexibly to each country context. It promotes the use of a common understanding on how attraction and retention interventions work, using a systems perspective

Indigenous communities’ responses to the COVID-19 pandemic and consequences for maternal and neonatal health in remote Peruvian Amazon: a qualitative study based on routine programme supervision

Aim: To explore indigenous communities’ responses to the COVID-19 pandemic and its consequences for maternal and neonatal health (MNH) care in the Peruvian Amazon. Methods: Mamás del Río is a community-based, MNH programme with comprehensive supervision covering monthly meetings with community health workers (CHW), community leaders and health facilities. With the onset of the lockdown, supervisors made telephone calls to discuss measures against COVID-19, governmental support, CHW activities in communities and provision of MNH care and COVID-19 preparedness at facilities. As part of the programme’s ongoing mixed methods evaluation, we analysed written summaries of supervisor calls collected during the first 2 months of Peru’s lockdown. Results: Between March and May 2020, supervisors held two rounds of calls with CHWs and leaders of 68 communities and staff from 17 facilities. Most communities banned entry of foreigners, but about half tolerated residents travelling to regional towns for trade and social support. While social events were forbidden, strict home isolation was only practised in a third of communities as conflicting with daily routine. By the end of April, first clusters of suspected cases were reported in communities. COVID-19 test kits, training and medical face masks were not available in most rural facilities. Six out of seven facilities suspended routine antenatal and postnatal consultations while two-thirds of CHWs resumed home visits to pregnant women and newborns. Conclusions: Home isolation was hardly feasible in the rural Amazon context and community isolation was undermined by lack of external supplies and social support. With sustained community transmission, promotion of basic hygiene and mask use becomes essential. To avoid devastating effects on MNH, routine services at facilities need to be urgently re-established alongside COVID-19 preparedness plans. Community-based MNH programmes could offset detrimental indirect effects of the pandemic and provide an opportunity for local COVID-19 prevention and containment

The development of solar power boat engine

With the increased of fuel energy demand and fear of depletion of the fossil fuel for year ahead makes most of boat user facing problem with burdened by higher cost of the fuel. Renewable energy has remarkably the only best solution for this problem. Hence, these projects proposed to solve the problem by replacing the fuel energy with the renewable solar power energy. The proposed of the solar power boat which will be consists of the solar panel (photovoltaic cell) as sunlight collector that act as the power generator that will be supported by the battery as storage power for the boat and the load which is dc motor that replace fuel engine. The charging process will be control by the solar charger controller that uses PWM operation method. Overall system will start by the sunlight converted to the electricity and then the generated power will be transferred to the battery. Then only that the load (dc motor) can be operated. Both of these charging and running the load will be operate together. With this solar power technology, we can reduce fuel usage. Moreover, these method helps reduce air pollution that produced by the fuel engin

Job preferences of nurses and midwives for taking up a rural job in Peru: a discrete choice experiment.

BACKGROUND: Robust evidence on interventions to improve the shortage of health workers in rural areas is needed. We assessed stated factors that would attract short-term contract nurses and midwives to work in a rural area of Peru. METHODS AND FINDINGS: A discrete choice experiment (DCE) was conducted to evaluate the job preferences of nurses and midwives currently working on a short-term contract in the public sector in Ayacucho, Peru. Job attributes, and their levels, were based on literature review, qualitative interviews and focus groups of local health personnel and policy makers. A labelled design with two choices, rural community or Ayacucho city, was used. Job attributes were tailored to these settings. Multiple conditional logistic regressions were used to assess the determinants of job preferences. Then we used the best-fitting estimated model to predict the impact of potential policy incentives on the probability of choosing a rural job or a job in Ayacucho city. We studied 205 nurses and midwives. The odds of choosing an urban post was 14.74 times than that of choosing a rural one. Salary increase, health center-type of facility and scholarship for specialization were preferred attributes for choosing a rural job. Increased number of years before securing a permanent contract acted as a disincentive for both rural and urban jobs. Policy simulations showed that the most effective attraction package to uptake a rural job included a 75% increase in salary plus scholarship for a specialization, which would increase the proportion of health workers taking a rural job from 36.4% up to 60%. CONCLUSIONS: Urban jobs were more strongly preferred than rural ones. However, combined financial and non-financial incentives could almost double rural job uptake by nurses and midwifes. These packages may provide meaningful attraction strategies to rural areas and should be considered by policy makers for implementation

Continuous Training and Certification in Neonatal Resuscitation in Remote Areas Using a Multi-Platform Information and Communication Technology Intervention, Compared to Standard Training: A Randomized Cluster Trial Study Protocol

Background: About 10% of all newborns may have difficulty breathing and require support by trained personnel. In Peru, 90% of deliveries occur in health facilities. However, there is not a national neonatal resuscitation and certification program for the public health sector. In addition, the Andes and the Amazon regions concentrate large rural remote areas, which further limit the implementation of training programs and the accomplishment of continuous certification. Neonatal resuscitation training through the use of Information, Communication and Technology (ICT) tools, running on computers, tablets or mobile phones, may overcome such limitations. This strategy allows online and offline access to educational resources, paving the way to more frequent and efficient training, and certification processes. Objective: To evaluate the effects of a neonatal resuscitation training and certification program that uses a Multi-Platform ICT (MP-ICT) strategy on neonatal health care in remote areas. Methods: We propose to conduct the study through a cluster-randomized trial, where the study and analysis unit is the health care facility. Eligible facilities will include primary and secondary health care level facilities that are located in provinces with neonatal mortality rates higher than 15 per 1,000 live births. We will compare the proportion of newborns with a heart rate ≥100 beats per minute at two minutes after birth in health care facilities that receive MP-ICT training and certification implementation, with those that receive standard training and certification. Discussion: We expect that the intervention will be shown as more effective than the current standard of care. We are prepared to include it within a national neonatal resuscitation training and certification program to be implemented at national scale together with policymakers and other key stakeholders. Trial registration: ClinicalTrials.gov Nº NCT03210194 Status of the study: This study is enrolling participants by invitation only. Study protocol version 1.1 – March 31st, 201

Factors behind job preferences of Peruvian medical, nursing and midwifery students: a qualitative study focused on rural deployment

Background: Deployment of health workforce in rural areas is critical to reach universal health coverage. Students? perceptions towards practice in rural areas likely influence their later choice of a rural post. We aimed at exploring perceptions of students from health professions about career choice, job expectations, motivations and potential incentives to work in a rural area. Methods: In-depth interviews and focus groups were conducted among medical, nursing and midwifery students from universities of two Peruvian cities (Ica and Ayacucho). Themes for assessment and analysis included career choice, job expectations, motivations and incentives, according to a background theory a priori built for the study purpose. Results: Preference for urban jobs was already established at this undergraduate level. Solidarity, better income expectations, professional and personal recognition, early life experience and family models influenced career choice. Students also expressed altruism, willingness to choose a rural job after graduation and potential responsiveness to incentives for practising in rural areas, which emerged more frequent from the discourse of nursing and midwifery students and from all students of rural origin. Medical students expressed expectations to work in large urban hospitals offering higher salaries. They showed higher personal, professional and family welfare expectations. Participants consistently favoured both financial and non-financial incentives. Conclusions: Nursing and midwifery students showed a higher disposition to work in rural areas than medical doctors, which was more evident in students of rural origin. Our results may be useful to improve targeting and selection of undergraduate students, to stimulate the inclination of students to choose a rural job upon graduation and to reorient school programmes towards the production of socially committed health professionals. Policymakers may also consider using our results when planning and implementing interventions to improve rural deployment of health professionals