Health sector decentralization and Indonesia ' s nutrition programs : opportunities and challenges

This policy concept paper is intended to assist the center in navigating the tension between opportunities and challenges as activities are adapted to the decentralized national nutrition policy, and to help guide districts and provinces in the conduct o f locally appropriate nutrition programs. The paper synthesizes the findings of an extensive study undertaken by the World Bank with a summary of the results, while the conclusions are discussed in detail in the four annexes. It begins with a review of the accomplishments and remaining nutrition challenges for Indonesia. It then turns to look at the regional diversity in Indonesia ' s nutrition challenges and asks which type of nutrition programs are most cost-effective. The paper concludes with an assessment of the existing institutional arrangement for nutrition service delivery, and discusses steps Indonesia can take to further improve population nutrition and health. The annexes provide extensive data and analysis to shed light on the opportunities and challenges in the new institutional environment.Health Monitoring & Evaluation,Nutrition,Early Child and Children ' s Health,Population Policies,Rural Development Knowledge & Information Systems

Weekly variability of hydrography and transport of northwestern inflows into the northern North Sea

Quantifying the variability of North Sea inflows and understanding the temporal variability of their physical properties are essential for understanding, modelling and managing the ecosystems of the North Sea. The Joint North Sea Information System (JONSIS) line hydrographic section crosses the path of the main inflows of Atlantic water into the northwestern North Sea. We use observations from an autonomous underwater glider to observe the inflows at high spatial and temporal resolutions. The glider completed 10 partial sections of the JONSIS line in October and November of 2013. Key water masses of the inflow are identified; their spatial distribution varies greatly from section to section. This is not apparent from long-running ship surveys of the JONSIS line, which are generally several months apart. In particular, the distribution of water of most recent Atlantic origin varies as summer stratification decays throughout autumn: at the start of the deployment it is present as a thin layer beneath the thermocline; at the end of the deployment, it occupies the full depth of the water column. Thermohaline flow, i.e. that which is driven by horizontal density gradients, is focused into three or four jets (approximately 10 km wide). Jets as narrow as these have not previously been observed in the region. We also observe baroclinic eddies. The thermohaline transport of the inflows is compared with the absolute transport that is derived by referencing geostrophic shear to the glider's dive-average current. Thermohaline transport (approximately 0.2 Sv) is consistently smaller than absolute transport (approximately 0.5 Sv). The week-to-week variability in hydrography and flow structure identified in this study is relevant to on-going efforts to define a background state against which the nature of anthropogenic changes can be assessed, and future modelling efforts should represent the spatial and temporal variability that we have identified

Ventilation of the Arabian Sea Oxygen Minimum Zone by Persian Gulf Water

Dense overflows from marginal seas are critical pathways of oxygen supply to the Arabian Sea oxygen minimum zone (OMZ), yet these remain inadequately understood. Climate models struggle to accurately reproduce the observed extent and intensity of the Arabian Sea OMZ due to their limited ability to capture processes smaller than their grid scale, such as dense overflows. Multi-month repeated sections by underwater gliders off the coast of Oman resolve the contribution of dense Persian Gulf Water (PGW) outflow to oxygen supply within the Arabian Sea OMZ. We characterize PGW properties, seasonality, transport and mixing mechanisms to explain local processes influencing water mass transformation and oxygen fluxes into the OMZ. Atmospheric forcing at the source region and eddy mesoscale activity in the Gulf of Oman control spatiotemporal variability of PGW as it flows along-shelf off the northern Omani coast. Subseasonally, it is modulated by stirring and shear-driven mixing driven by eddy-topography interactions. The oxygen transport from PGW to the OMZ is estimated to be 1.3 Tmol yr−1 over the observational period, with dramatic inter- and intra-annual variability (±1.6 Tmol yr−1). We show that this oxygen is supplied to the interior of the OMZ through the combined action of double-diffusive and shear-driven mixing. Intermittent shear-driven mixing enhances double-diffusive processes, with mechanical shear conditions (Ri < 0.25) prevailing 14% of the time at the oxycline. These findings enhance our understanding of fine-scale processes influencing oxygen dynamics within the OMZ that can provide insights for improved modeling and prediction efforts

Turbulent kinetic energy dissipation rate and associated fluxes in the western tropical Atlantic estimated from ocean glider observations

Ocean gliders enable us to collect the high-resolution microstructure observations necessary to calculate the dissipation rate of turbulent kinetic energy, ε, on timescales of weeks to months: far longer than is normally possible using traditional ship-based platforms. Slocum gliders have previously been used to this end; here, we report the first detailed estimates of ε calculated using the Batchelor spectrum method on observations collected by a FP07 fast thermistor mounted on a Seaglider. We use these same fast thermistor observations to calculate ε following the Thorpe scale method and find very good agreement between the two methods. The Thorpe scale method yields larger values of ε, but the average difference, which is less than an order of magnitude, is smaller than reported elsewhere. The spatio-temporal distribution of ε is comparable for both methods. Maximum values of ε (10−7 W kg−1) are observed in the surface mixed layer; values of approximately 10−9 W kg−1 are observed between approximately 200 and 500 m depth. These two layers are separated by a 100 m thick layer of low ε (10−10 W kg−1), which is co-located with a high-salinity layer of Subtropical Underwater and a peak in the strength of stratification. We calculate the turbulent heat and salt fluxes associated with the observed turbulence. Between 200 and 500 m, ε induces downward fluxes of both properties that, if typical of the annual average, would have a very small influence on the heat and salt content of the overlying salinity-maximum layer. We compare these turbulent fluxes with two estimates of double-diffusive fluxes that occur in regions susceptible to salt fingers, such as the western tropical Atlantic. We find that the double-diffusive fluxes of both heat and salt are larger than the corresponding turbulent fluxes

Injection of oxygenated Persian Gulf Water into the southern Bay of Bengal

Persian Gulf Water (PGW) is an oxygenated, high-salinity water mass that has recently been detected in the Bay of Bengal (BoB). However, little is known about the transport pathways of PGW into the BoB. Ocean glider observations presented here demonstrate the presence of PGW in the southwestern BoB. Output from an ocean reanalysis product shows that this PGW signal is associated with a northward-flowing filament of high-salinity water. Particle tracking experiments reveal two pathways: one in the eastern Arabian Sea that takes a minimum of 2 years and another in the western Arabian Sea that takes a minimum of 3 years. The western pathway connects to the BoB via equatorial currents. The greatest influx of PGW occurs between 82° and 87°E during the southwest monsoon. We propose that injection of PGW to the BoB oxygen minimum zone (OMZ) contributes to keeping oxygen concentrations in the BoB above the level at which denitrification occurs

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

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey

In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs

Developing a core outcome set for fistulising perianal Crohn's disease

OBJECTIVE: Lack of standardised outcomes hampers effective analysis and comparison of data when comparing treatments in fistulising perianal Crohn's disease (pCD). Development of a standardised set of outcomes would resolve these issues. This study provides the definitive core outcome set (COS) for fistulising pCD. DESIGN: Candidate outcomes were generated through a systematic review and patient interviews. Consensus was established via a three-round Delphi process using a 9-point Likert scale based on how important they felt it was in determining treatment success culminating in a final consensus meeting. Stakeholders were recruited nationally and grouped into three panels (surgeons and radiologists, gastroenterologists and IBD specialist nurses, and patients). Participants received feedback fromtheir panel(in the second round) andall participants(in the third round) to allow refinement of their scores. RESULTS: A total of 295 outcomes were identified from systematic reviews and interviews that were categorised into 92 domains. 187 stakeholders (response rate 78.5%) prioritised 49 outcomes through a three-round Delphi study.The final consensus meeting of 41 experts and patients generated agreement on an eight domain COS. The COS comprised three patient-reported outcome domains (quality of life, incontinence and a combined score of patient priorities) and five clinician-reported outcome domains (perianal disease activity, development of new perianal abscess/sepsis, new/recurrent fistula, unplanned surgery and faecal diversion). CONCLUSION: A fistulising pCD COS has been produced by all key stakeholders. Application of the COS will reduce heterogeneity in outcome reporting, thereby facilitating more meaningful comparisons between treatments, data synthesis and ultimately benefit patient care

The Deepest Radio Observations of Nearby Type IA Supernovae: Constraining Progenitor Types and Optimizing Future Surveys

We report deep radio observations of nearby Type Ia Supernovae (SNe Ia) with the electronic Multi-Element Radio Linked Interferometer Net-work (e-MERLIN), and the Australia Telescope Compact Array (ATCA). No detections were made. With standard assumptions for the energy densities of relativistic electrons going into a power-law energy distribution, and the magnetic field strength (epsilon_e = epsilon_B = 0.1), we arrive at the upper limits on mass-loss rate for the progenitor system of SN 2013dy (2016coj, 2018gv, 2018pv, 2019np), to be less than 12 (2.8,1.3, 2.1, 1.7)EE(-8) solar masses per year (for a wind speed of 100 km/s). To SNe 2016coj, 2018gv, 2018pv and 2019np we add radio data for 17 other nearby SNe Ia, and model their non-detections. With the same model as described, all 21 SNe Ia have mass-loss rates less than 4EE(-8) solar masses per year (for a wind speed of 100 km/s). We compare those limits with the expected mass loss rates in different single-degenerate progenitor scenarios. We also discuss how information on epsilon_e and epsilon_B can be obtained from late observations of SNe Ia and the youngest SN Ia remnant detected in radio, G1.9+0.3, as well as stripped-envelope core-collapse SNe. We highlight SN 2011dh, and argue for epsilon_e approximately equal to 0.1 and epsilon_B approximately equal to 0.0033. Finally, we discuss strategies to observe at radio frequencies to maximize the chance of detection, given the time since explosion, the distance to the supernova and the telescope sensitivity