The change in capacity and service delivery at public and private hospitals in Turkey: A closer look at regional differences

<p>Abstract</p> <p>Background</p> <p>Substantial regional health inequalities have been shown to exist in Turkey for major health indicators. Turkish data on hospitals deserves a closer examination with a special emphasis on the regional differences in the context of the rapid privatization of the secondary or tertiary level health services.</p> <p>This study aims to evaluate the change in capacity and service delivery at public and private hospitals in Turkey between 2001-2006 and to determine the regional differences.</p> <p>Methods</p> <p>Data for this retrospective study was provided from Statistical Almanacs of Inpatient Services (2001-2006). Hospitals in each of the 81 provinces were grouped into two categories: public and private. Provinces were grouped into six regions according to a development index composed by the State Planning Organisation. The number of facilities, hospital beds, outpatient admissions, inpatient admissions (per 100 000), number of deliveries and surgical operations (per 10 000) were calculated for public and private hospitals in each province and region. Regional comparisons were based on calculation of ratios for Region 1(R1) to Region 6(R6).</p> <p>Results</p> <p>Public facilities had a fundamental role in service delivery. However, private sector grew rapidly in Turkey between 2001-2006 in capacity and service delivery. In public sector, there were 2.3 fold increase in the number of beds in R1 to R6 in 2001. This ratio was 69.9 fold for private sector. The substantial regional inequalities in public and private sector decreased for the private sector enormously while a little decrease was observed for the public sector. In 2001 in R1, big surgical operations were performed six times more than R6 at the public sector whereas the difference was 117.7 fold for the same operations in the same regions for the private sector. These ratios decreased to 3.6 for the public sector and 13.9 for the private sector in 2006.</p> <p>Conclusions</p> <p>The private health sector has grown enormously between 2001-2006 in Turkey including the less developed regions of the country. Given the fact that majority of people living in these underdeveloped regions are uninsured, the expansion of the private sector may not contribute in reducing the inequalities in access to health care. In fact, it may widen the existing gap for access to health between high and low income earners in these underdeveloped regions.</p

Task sharing in Zambia: HIV service scale-up compounds the human resource crisis

BACKGROUND: Considerable attention has been given by policy makers and researchers to the human resources for health crisis in Africa. However, little attention has been paid to quantifying health facility-level trends in health worker numbers, distribution and workload, despite growing demands on health workers due to the availability of new funds for HIV/AIDS control scale-up. This study analyses and reports trends in HIV and non-HIV ambulatory service workloads on clinical staff in urban and rural district level facilities. METHODS: Structured surveys of health facility managers, and health services covering 2005-07 were conducted in three districts of Zambia in 2008 (two urban and one rural), to fill this evidence gap. Intra-facility analyses were conducted, comparing trends in HIV and non-HIV service utilisation with staff trends. RESULTS: Clinical staff (doctors, nurses and nurse-midwives, and clinical officers) numbers and staff population densities fell slightly, with lower ratios of staff to population in the rural district. The ratios of antenatal care and family planning registrants to nurses/nurse-midwives were highest at baseline and increased further at the rural facilities over the three years, while daily outpatient department (OPD) workload in urban facilities fell below that in rural facilities. HIV workload, as measured by numbers of clients receiving antiretroviral treatment (ART) and prevention of mother to child transmission (PMTCT) per facility staff member, was highest in the capital city, but increased rapidly in all three districts. The analysis suggests evidence of task sharing, in that staff designated by managers as ART and PMTCT workers made up a higher proportion of frontline service providers by 2007. CONCLUSIONS: This analysis of workforce patterns across 30 facilities in three districts of Zambia illustrates that the remarkable achievements in scaling-up HIV/AIDS service delivery has been on the back of sustained non-HIV workload levels, increasing HIV workload and stagnant health worker numbers. The findings are based on an analysis of routine data that are available to district and national managers. Mixed methods research is needed, combining quantitative analyses of routine health information with follow-up qualitative interviews, to explore and explain workload changes, and to identify and measure where problems are most acute, so that decision makers can respond appropriately. This study provides quantitative evidence of a human resource crisis in health facilities in Zambia, which may be more acute in rural areas

Water exercises and quality of life during pregnancy

<p>Abstract</p> <p>Background</p> <p>In Brazil, concern with the quality of life of pregnant women is one of the points emphasized in the Program for the Humanization of Prenatal Care and Childbirth launched in 2000. However, there are few references in the literature on the role of either land or water-based physical exercise on women's quality of life during pregnancy. The purpose of this study was to evaluate the effects of a physical exercise program of water aerobics on the quality of life (QOL) of sedentary pregnant women.</p> <p>Methods</p> <p>A comparative observational study involving sedentary low-risk pregnant women bearing a single fetus with gestational age less than 20 weeks at the time of admission to the study, who were receiving antenatal care at a public health service. One group of 35 women was given routine antenatal care, while another group of 31 women, in addition to receiving the same routine care as the first group, also participated in three classes of water aerobics per week. QOL was evaluated by applying the WHOQOL-BREF questionnaire in both groups at the 20^th, 28^thand 36^thweeks of pregnancy. In the same occasions, women also answered another questionnaire about their experience with pregnancy and antenatal care.</p> <p>Results</p> <p>The great majority of the participants considered that the practice of water aerobics had benefitted them in some way. QOL scores were found to be high in both groups during follow-up. There was no association between the practice of water aerobics and QOL.</p> <p>Conclusions</p> <p>Further studies involving larger sample sizes should be conducted in different sociocultural contexts and/or using other instruments to adequately evaluate the QOL of women during pregnancy.</p

Socio-economic differences and health seeking behaviour for the diagnosis and treatment of malaria: a case study of four local government areas operating the Bamako initiative programme in south-east Nigeria

BACKGROUND: Malaria is one of the leading causes of mortality and morbidity in Nigeria. It is not known how user fees introduced under the Bamako Initiative (BI) system affect healthcare seeking among different socio-economic groups in Nigeria for diagnosis and treatment of malaria. Reliable information is needed to initiate new policy thrusts to protect the poor from the adverse effect of user fees. METHODS: Structured questionnaires were used to collect information from 1594 female household primary care givers or household head on their socio-economic and demographic status and use of malaria diagnosis and treatment services. Principal components analysis was used to create a socio-economic status index which was decomposed into quartiles and chi-square for trends was used to calculate for any statistical difference. RESULTS: The study showed that self diagnosis was the commonest form of diagnosis by the respondents. This was followed by diagnosis through laboratory tests, community health workers, family members and traditional healers. The initial choice of care for malaria was a visit to the patent medicine dealers for most respondents. This was followed by visit to the government hospitals, the BI health centres, traditional medicine healers, private clinics, community health workers and does nothing at home. Furthermore, the private health facilities were the initial choice of treatment for the majority with a decline among those choosing them as a second source of care and an increase in the utilization of public health facilities as a second choice of care. Self diagnosis was practiced more by the poorer households while the least poor used the patent medicine dealers and community health workers less often for diagnosis of malaria. The least poor groups had a higher probability of seeking treatment at the BI health centres (creating equity problem in BI), hospitals, and private clinics and in using laboratory procedures. The least poor also used the patent medicine dealers and community health workers less often for the treatment of malaria. The richer households complained more about poor staff attitude and lack of drugs as their reasons for not attending the BI health centres. The factors that encourage people to use services in BI health centres were availability of good services, proximity of the centres to the homes and polite health workers. CONCLUSIONS: Factors deterring people from using BI centres should be eliminated. The use of laboratory services for the diagnosis of malaria by the poor should be encouraged through appropriate information, education and communication which at the long run will be more cost effective and cost saving for them while devising means of reducing the equity gap created. This could be done by granting a properly worked out and implemented fee exemptions to the poor or completely abolishing user fees for the diagnosis and treatment of malaria in BI health centres

Combining evidence and values in priority setting: testing the balance sheet method in a low-income country

<p>Abstract</p> <p>Background</p> <p>Procedures for priority setting need to incorporate both scientific evidence and public values. The aim of this study was to test out a model for priority setting which incorporates both scientific evidence and public values, and to explore use of evidence by a selection of stakeholders and to study reasons for the relative ranking of health care interventions in a setting of extreme resource scarcity.</p> <p>Methods</p> <p>Systematic search for and assessment of relevant evidence for priority setting in a low-income country. Development of a balance sheet according to Eddy's explicit method. Eight group interviews (n-85), using a modified nominal group technique for eliciting individual and group rankings of a given set of health interventions.</p> <p>Results</p> <p>The study procedure made it possible to compare the groups' ranking before and after all the evidence was provided to participants. A rank deviation is significant if the rank order of the same intervention differed by two or more points on the ordinal scale. A comparison between the initial rank and the final rank (before deliberation) showed a rank deviation of 67%. The difference between the initial rank and the final rank after discussion and voting gave a rank deviation of 78%.</p> <p>Conclusion</p> <p>Evidence-based and deliberative decision-making does change priorities significantly in an experimental setting. Our use of the balance sheet method was meant as a demonstration project, but could if properly developed be feasible for health planners, experts and health workers, although more work is needed before it can be used for laypersons.</p

Sexual behaviors and their correlates among young people in Mauritius: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Little is known about the HIV/AIDS epidemic in the Indian Ocean region, including Mauritius. National records suggest a prevalence of HIV in Mauritius of < 1% in the general population, which is one of the lowest prevalence rates in southern Africa. However, HIV-positive cases have been increasing recently in Mauritius. We conducted a cross-sectional survey in January 2003 to assess the prevalence of HIVrelated sexual behaviors and their correlates among young people aged 15–24 years in Mauritius.</p> <p>Methods</p> <p>We identified 1200 participants using two-stage cluster sampling. Demographic, social, sexual, and knowledge of HIV/AIDS data were obtained in face-to-face interviews using a structured questionnaire administered by trained interviewers. The prevalence of sexual behaviors was described in relation to gender, and the correlates of ever having had sex and nonuse of condom at last sex were analyzed using logistic regression.</p> <p>Results</p> <p>In the target population, 30.9% of males and 9.7% of females reported a history of sexual intercourse. Of the currently sexually active participants, 50.6% of men and 71.2% of women did not use condoms at their last sexual encounter. Logistic regression revealed that work experience and marijuana use were significantly associated with men's sexual experience, whereas being out of school and drinking experience were significantly associated with women's sexual experience. For both men and women, being Christian and visiting nightclubs were associated with having ever had sexual intercourse (P < 0.05). In addition, not using a condom at the first sexual encounter and lack of exposure to a nongovernmental organization (NGO) dealing with HIV/AIDS were associated with the nonuse of condoms at the last sexual encounter (P < 0.05).</p> <p>Conclusion</p> <p>Young people in Mauritius are at risk of a future HIV epidemic because behaviors predisposing to HIV infection are prevalent among sexually experienced youth. A focused prevention program targeting young people should be reinforced as part of the National AIDS Control Program, taking into account the predictors of sexual behaviors identified here.</p

Outputs, cost and efficiency of public sector centres for prevention of mother to child transmission of HIV in Andhra Pradesh, India

<p>Abstract</p> <p>Background</p> <p>Prevention of mother to child transmission (PMTCT) is an important part of the effort to control HIV. PMTCT services are mostly provided at public sector government hospitals in India. Systematic data on the cost and efficiency of providing PMTCT services in India are not available readily for further planning.</p> <p>Methods</p> <p>Cost and output data were collected at 16 sampled PMTCT centres in the south Indian state of Andhra Pradesh using standardized methods. The services provided were analysed, and the relation of unit cost of services with scale was assessed.</p> <p>Results</p> <p>In the 2005–2006 fiscal year, 125,073 pregnant women received PMTCT services at the 16 centres (range 2,939 to 20,896, median 5,679). The overall HIV positive rate among those tested was 1.67%. Of the total economic cost, the major components were personnel (47.3%) and recurrent goods (31.7%). For the 16 PMTCT centres, the average economic cost per post-HIV-test counselled pregnant woman was Indian Rupees (INR) 98.9 (US$2.23), ranging 2.7-fold from INR 71.4 (US$ 1.61) to INR 189.9 (US$4.29). The economic cost per mother-neonate pair who received nevirapine had a higher variation, ranging 41-fold for the 16 centres from INR 4,354 (US$ 98) to INR 179,175 (US$4,047), average INR 10,210 (US$ 231), with very high unit cost at some centres where HIV prevalence among pregnant women and the total volume of services were both low. Scale had a significant inverse relation with both of the unit costs, per post-HIV-test counselled pregnant woman and per mother-neonate pair who received nevirapine. In addition, HIV prevalence among pregnant women had a significant inverse relation with unit cost per mother-neonate pair who received nevirapine.</p> <p>Conclusion</p> <p>Although the variation between PMTCT centres for unit cost per post-HIV-test counselled pregnant woman was modest that per mother-neonate pair receiving nevirapine was over 40-fold. The extremely high unit cost for each mother-neonate pair receiving nevirapine at some centres suggests that the new approach of combining PMTCT services with voluntary counselling and testing services that has recently been started in India could potentially offer better efficiency.</p

Which health care facilities do adult malawian antiretroviral therapy patients utilize during intercurrent illness? a cross sectional study

<p>Abstract</p> <p>Background</p> <p>Antiretroviral therapy (ART) clinic populations have expanded enormously in the successful Malawi ART scale-up programme. Overcrowding, long waiting times and living far away from the clinic may affect the extent to which patients use their ART clinic for intercurrent illnesses.</p> <p>Methods</p> <p>We interviewed patients of a large urban ART clinic in Blantyre, Malawi, during routine visits about the choice of health care facility during recent illness episodes.</p> <p>Results</p> <p>Out of 346 enrolled adults, mean age 39.8 (range 18-70) years, 54.3% female, 202 (58%) reported one or more illness in the past 6 months, during which 85 (42.1%; 95%-confidence interval: 36.9-47.3%) did not utilize their own clinic. Long distance to the clinic was the main subjective reason, while low education attainment, rural residence, perceived mild illness and dissatisfaction with the ART service were associated with not using their own clinic in multivariate analyses. Of all participants, 83.6% were satisfied with the service provided; only 6.1% were aware of the full service package of the ART clinic.</p> <p>Conclusions</p> <p>ART patients often seek health care outside their own clinic, which may have detrimental effects, and has consequences for ART counseling content and reporting of ART information in health passports.</p

Cesarean and Vbac Rates Among Immigrant vs. Native-Born Women: A Retrospective Observational Study From Taiwan Cesarean Delivery and Vbac Among Immigrant Women in Taiwan

Background Cultural and ethnic roots impact women\u27s fertility and delivery preferences This study investigated whether the likelihood of cesarean delivery, primary cesarean, and vaginal delivery after cesarean (VBAC) varies by maternal national origin. Methods We conducted a nation-wide, population-based, observational study using secondary data from Taiwan. De-identified data were obtained on all 392,246 singleton live births (≥500 g; ≥20 weeks) born to native-born Taiwanese, Vietnamese and mainland Chinese-born mothers between January 1 2006 and December 31 2007 from Taiwan\u27s nation-wide birth certificate data. Our analytic samples consisted of the following: for overall cesarean likelihood 392,246 births, primary cesarean 336,766 (excluding repeat cesarean and VBAC), and VBAC 55,480 births (excluding primary cesarean and vaginal births without previous cesarean). Our main outcome measures were the odds of cesarean delivery, primary cesarean delivery and VBAC for Vietnamese and Chinese immigrant mothers relative to Taiwanese mothers, using multiple regression analyses to adjust for maternal and neonatal characteristics, paternal age, institutional setting, and major obstetric complications. Results Unadjusted overall cesarean, primary cesarean, and VBAC rates were 33.9%, 23.0% and 4.0% for Taiwanese, 27.6%, 20.1% and 5.0% for mainland Chinese, and 19.3%, 13.9 and 6.1% for Vietnamese respectively. Adjusted for confounders, Vietnamese mothers were less likely than native-born Taiwanese to have overall and primary cesarean delivery (OR = 0.59 and 0.58 respectively), followed by Chinese mothers (both ORs = 0.90 relative to native-born Taiwanese). Vietnamese mothers were most likely to have successful VBAC (OR = 1.58), followed by Chinese mothers (OR = 1.25). Conclusion Immigrant Vietnamese and Chinese mothers have lower odds of cesarean and higher VBAC odds than native-born Taiwanese, consistent with lower cesarean rates prevailing in their home countries (Vietnam 10.1%; mainland China 20% - 50% rural and urban respectively)