How Can Health Systems Research Reach the Worst-Off? A Conceptual Exploration

Background: Health systems research is increasingly being conducted in low and middle-income countries (LMICs). Such research should aim to reduce health disparities between and within countries as a matter of global justice. For such research to do so, ethical guidance that is consistent with egalitarian theories of social justice proposes it ought to (amongst other things) focus on worst-off countries and research populations. Yet who constitutes the worst-off is not well-defined. Methods and Results: By applying existing work on disadvantage from political philosophy, the paper demonstrates that (at least) two options exist for how to define the worst-off upon whom equity-oriented health systems research should focus: those who are worst-off in terms of health or those who are systematically disadvantaged. The paper describes in detail how both concepts can be understood and what metrics can be relied upon to identify worst-off countries and research populations at the sub-national level (groups, communities). To demonstrate how each can be used, the paper considers two real-world cases of health systems research and whether their choice of country (Uganda, India) and research population in 2011 would have been classified as amongst the worst-off according to the proposed concepts. Conclusions: The two proposed concepts can classify different countries and sub-national populations as worst-off. It is recommended that health researchers (or other actors) should use the concept that best reflects their moral commitments—namely, to perform research focused on reducing health inequalities or systematic disadvantage more broadly. If addressing the latter, it is recommended that they rely on the multidimensional poverty approach rather than the income approach to identify worst-off populations

Exploring ethical considerations for the use of biological and physiological markers in population-based surveys in less developed countries

BACKGROUND: The health information needs of developing countries increasingly include population-based estimates determined by biological and physiological measures. Collection of data on these biomarkers requires careful reassessment of ethical standards and procedures related to issues of safety, informed consent, reporting, and referral policies. This paper reviews the survey practices of health examination surveys that have been conducted in developed nations and discusses their application to similar types of surveys proposed for developing countries. DISCUSSION: The paper contends that a unitary set of ethical principles should be followed for surveys around the world that precludes the danger of creating double standards (and implicitly lowers standards for work done in developing countries). Global ethical standards must, however, be interpreted in the context of the unique historical and cultural context of the country in which the work is being done. Factors that influence ethical considerations, such as the relationship between investigators in developed and developing countries are also discussed. SUMMARY: The paper provides a set of conclusions reached through this discussion and recommendations for the ethical use of biomarkers in populations-based surveys in developing countries

Modeling the cost effectiveness of injury interventions in lower and middle income countries: opportunities and challenges

BACKGROUND: This paper estimates the cost-effectiveness of five interventions that could counter injuries in lower and middle income countries(LMICs): better traffic enforcement, erecting speed bumps, promoting helmets for bicycles, promoting helmets for motorcycles, and storing kerosene in child proof containers. METHODS: We adopt an ingredients based approach to form models of what each intervention would cost in 6 world regions over a 10 year period discounted at both 3% and 6% from both the governmental and societal perspectives. Costs are expressed in local currency converted into US $2001. Each of these interventions has been assessed for effectiveness in a LMIC in limited region, these effectiveness estimates have been used to form models of disability adjusted life years (DALYs) averted for various regions, taking account of regional differences in the baseline burden of injury. RESULTS: The interventions modeled in this paper have cost effectiveness ratios ranging from US$5 to $556 per DALY averted depending on region. Depending on local acceptability thresholds many of them could be judged cost-effective relative to interventions that are already adopted. Enhanced enforcement of traffic regulations is the most cost-effective interventions with an average cost per DALY of$64 CONCLUSION: Injury counter measures appear to be cost-effective based on models. More evaluations of real interventions will help to strengthen the evidence basis

Violence against Children: A Challenge for Public Health in Pakistan

World Health Organization has identified violence against children as a growing public-health issue with a global magnitude. This paper explored violence against children as a challenge in the developing world using Pakistan as a case study. A systematic review of existing research and literature on violence against children was followed by assessing the magnitude of this challenge and its impact on policy. Most research done in Pakistan is observational, descriptive, and anecdotal with data collected through survey methods and interviews with small sample sizes. The findings suggest that the confluence of macro risk factors, such as poverty, poor legal protections, illiteracy, large family size, and unemployment, create an enabling environment for violence against children. Lack of empirical data makes it difficult to assess the magnitude of this issue. The health problems reported and the extent of human potential destroyed are unknown. Conclusion calls for focused research to examine the prevalence, potential interventions, and policies in Pakistan

Cost-effectiveness of traffic enforcement: case study from Uganda

BACKGROUND: In October 2004, the Ugandan Police department deployed enhanced traffic safety patrols on the four major roads to the capital Kampala. OBJECTIVE: To assess the costs and potential effectiveness of increasing traffic enforcement in Uganda. METHODS: Record review and key informant interviews were conducted at 10 police stations along the highways that were patrolled. Monthly data on traffic citations and casualties were reviewed for January 2001 to December 2005; time series (ARIMA) regression was used to assess for a statistically significant change in traffic deaths. Costs were computed from the perspective of the police department in $US 2005. Cost offsets from savings to the health sector were not included. RESULTS: The annual cost of deploying the four squads of traffic patrols (20 officers, four vehicles, equipment, administration) is estimated at$72,000. Since deployment, the number of citations has increased substantially with a value of $327 311 annually. Monthly crash data pre- and post-intervention show a statistically significant 17$603 per death averted or $27 per life year saved discounted at 3$300 GDP per capita). CONCLUSION: The costs of traffic safety enforcement are low in comparison to the potential number of lives saved and revenue generated. Increasing enforcement of existing traffic safety norms can prove to be an extremely cost-effective public health intervention in low-income countries, even from a government perspective

A Million Person Household Survey: Understanding the Burden of Injuries in Bangladesh

Ninety percent of lives claimed by injuries occur in low- and middle-income countries. This special issue, A Million Person Household Survey: Understanding the Burden of Injuries in Bangladesh, aims to assess these injuries—including falls, drowning, burns, road traffic injuries — to inform efforts to reduce the burden they cast on millions of people and families in a low income country. This issue offers a unique collection of research on the epidemiology of fatal and non-fatal injuries in Bangladesh. Based on a survey of more than one million people, this research—conducted by the International Injury Research Unit, Department of International Health at the Johns Hopkins Bloomberg School of Public Health and two Bangladesh partners, the Center for Injury Prevention and Research and the International Center for Diarrheal Disease Research, Bangladesh with funding from Bloomberg Philanthropies, was part of a large-scale, population-based, child-drowning prevention project called “Saving of Lives from Drowning in Bangladesh.” The project tested the large-scale effectiveness and cost-effectiveness of evidence-based interventions to reduce drowning related deaths for children less than five years of age (reported elsewhere). We hope this data will be useful to researchers, students, practitioners and national decision makers

Policy Implementation: Teachers’ Role as First Responders in Emergencies and Disasters

During the past decade, the schoolchildren faced many disasters and emergencies originating from natural and man-made sources. The safety of schoolchildren rests with school management and teachers. This study aimed to assess teachers' awareness with regard to disaster prevention and health, safety, security, and environment (HSSE) policies at primary schools in Pakistan. In addition, it explores the suitability of teachers to perform as emergency handlers in the absence of school nurses and resource officers (SROs). The study involved a qualitative study, based on open-ended interviews from a sample of 25 school teachers. Methodology triangulation was applied to reduce bias. Results revealed that the majority of teachers do not know about national policies related to school safety and security. Most of the teachers had been assigned additional roles as safety officers at the school, though they lack relevant training. Moreover, neither safety nor security aspects are incorporated into national educational policy. This study was the first study on Pakistani teachers’roles as emergency first responders. With the highest rate of attacks on educational institutions globally, the region still lacks a coherent policy structure. The study found numerous inconsistencies in public policies. It seeks to contribute to the literature to better understand the educational safety environment at both the ground and policy levels

Patterns of injury and violence in Yaoundé Cameroon: an analysis of hospital data.

BackgroundInjuries are quickly becoming a leading cause of death globally, disproportionately affecting sub-Saharan Africa, where reports on the epidemiology of injuries are extremely limited. Reports on the patterns and frequency of injuries are available from Cameroon are also scarce. This study explores the patterns of trauma seen at the emergency ward of the busiest trauma center in Cameroon's capital city.Materials and methodsAdministrative records from January 1, 2007, through December 31, 2007, were retrospectively reviewed; information on age, gender, mechanism of injury, and outcome was abstracted for all trauma patients presenting to the emergency ward. Univariate analysis was performed to assess patterns of injuries in terms of mechanism, date, age, and gender. Bivariate analysis was used to explore potential relationships between demographic variables and mechanism of injury.ResultsA total of 6,234 injured people were seen at the Central Hospital of Yaoundé's emergency ward during the year 2007. Males comprised 71% of those injured, and the mean age of injured patients was 29 years (SD = 14.9). Nearly 60% of the injuries were due to road traffic accidents, 46% of which involved a pedestrian. Intentional injuries were the second most common mechanism of injury (22.5%), 55% of which involved unarmed assault. Patients injured in falls were more likely to be admitted to the hospital (p < 0.001), whereas patients suffering intentional injuries and bites were less likely to be hospitalized (p < 0.001). Males were significantly more likely to be admitted than females (p < 0.001)DiscussionPatterns in terms of age, gender, and mechanism of injury are similar to reports from other countries from the same geographic region, but the magnitude of cases reported is high for a single institution in an African city the size of Yaoundé. As the burden of disease is predicted to increase dramatically in sub-Saharan Africa, immediate efforts in prevention and treatment in Cameroon are strongly warranted

Measuring the health of populations: explaining composite indicators

Indicators that summarise the health status of a population and that provide comparable measures of a population disease burden are increasingly vital tools for health policy decision making. Decisions concerning health systems across the world are greatly affected by changes in disease profiles and population dynamics, and must develop the capacity to respond to such changes effectively within the resources of each nation. Decisions must be based on evidence of the patterns of diseases, their risk factors and the effectiveness of alternative interventions. This paper focuses on the main approaches used for developing summary measures that include mortality and morbidity occurring in a population. It discusses the rationale for composite measures and reviews the origins of each main approach. The paper also examines methodological differences among these approaches making explicit the value choices that each entails, outlines the advantages and limitations of each measure, and shows how they relate to one another