The Importance of a Multi-Sectoral Approach to Food and Nutrition Security in Africa

One of the targets of the first Millennium Development Goals (MDG) is to s (MDG) is to reduce the proportion of people who suffer from hunger by half between 1990 and 2015, with hunger measured as the proportion of the population who are undernourished and the prevalence of children under five who are underweight. Many countries remain far from reaching this target, and much of the progress made has been eroded by the recent global food price and economic crises. As we enter the final five years to trying to achieve the MDGs, we look upon one of the trying to achieve the MDGs, we look upon one of the achieve the MDGs, we look upon one of the e the MDGs, we look upon one of the the MDGs, we look upon one of the greatest challenges of our time with one billion people hungry, 129 million and 195 million children underweight and stunted respectively and more than 2 billion people deficient in micronutrients

An Evaluation of Progress Toward the Millennium Development Goal One Hunger Target: A country‐level, food and nutrition security perspective

One of the targets of the first Millennium Development Goal (MDG) is to reduce the proportion of people who suffer from hunger by half between 1990 and 2015, with hunger measured as the proportion of the population who are undernourished and the prevalence of children under five who are underweight. Many countries remain far from reaching this target, and much of the progress made has been eroded by the recent global food price and economic crises. As we enter the final five years to achieve the MDGs, we look upon one of the greatest challenges of our time with one billion people hungry, 129 million and 195 million children underweight and stunted respectively and more than 2 billion people deficient in micronutrients. In light of these global trends, this report charts progress on the hunger component of the MDG 1 commitment, by reviewing country programs and policies and drawing attention to key lessons and future directions for the coming period. Case studies of programs and interventions within countries were reviewed, where the implementation and operational systems required to support reductions in hunger and undernutrition have the potential to shed light on what success and scale might look like. A number of types of programs were profiled, including prevention‐ and treatment‐based initiatives, food production interventions, multi‐sectoral programs, and safety net and food assistance approaches. The report examined both small‐scale community based programs as well as efforts to move interventions to national scale. The strongest lesson emerging from both community‐based and national efforts is that making rapid gains in reducing hunger and undernutrition is possible. There is little debate about the technical and scientific evidence underpinning interventions. We know what works. The challenge is integrating the delivery of these interventions within locally owned, locally appropriate systems that facilitate high levels of cost-effective coverage on a sustained basis, with substantive and prioritized financial commitment at the 2 national and international levels. Many of the case studies presented have found innovative ways to overcome historical barriers to implementation – from household‐level delivery systems, to subsidies for small holder farmers, to linking efforts to reduce hunger with wider efforts to empower women or create work and business opportunities. Evidence from the case studies also suggest that increasing economic growth alone, while necessary and important, is unlikely to be sufficient to address hunger and undernutrition. Food and nutrition security is complex, and requires efforts across a spectrum that includes enhancing food production while simultaneously increasing access and utilization with substantive political commitment to address the most vulnerable populations with an equitable, basic human rights lens approach (11). Finally, addressing hunger and undernutrition are inextricably linked to wider progress towards other MDG targets. They are both cause and consequence of gains in health, income, education, gender equality and the environment. A comprehensive approach to addressing hunger and nutrition will therefore require working on multiple fronts. While there may be no magic bullet or single recipe for success, the case studies highlighted in this report help us to understand what success might look like as we together define a future direction for 2015

A combined microfinance and training intervention can reduce HIV risk behaviour in young female participants.

OBJECTIVE: To assess effects of a combined microfinance and training intervention on HIV risk behavior among young female participants in rural South Africa. DESIGN: : Secondary analysis of quantitative and qualitative data from a cluster randomized trial, the Intervention with Microfinance for AIDS and Gender Equity study. METHODS: Eight villages were pair-matched and randomly allocated to receive the intervention. At baseline and after 2 years, HIV risk behavior was assessed among female participants aged 14-35 years. Their responses were compared with women of the same age and poverty group from control villages. Intervention effects were calculated using adjusted risk ratios employing village level summaries. Qualitative data collected during the study explored participants' responses to the intervention including HIV risk behavior. RESULTS: After 2 years of follow-up, when compared with controls, young participants had higher levels of HIV-related communication (adjusted risk ratio 1.46, 95% confidence interval 1.01-2.12), were more likely to have accessed voluntary counseling and testing (adjusted risk ratio 1.64, 95% confidence interval 1.06-2.56), and less likely to have had unprotected sex at last intercourse with a nonspousal partner (adjusted risk ratio 0.76, 95% confidence interval 0.60-0.96). Qualitative data suggest a greater acceptance of intrahousehold communication about HIV and sexuality. Although women noted challenges associated with acceptance of condoms by men, increased confidence and skills associated with participation in the intervention supported their introduction in sexual relationships. CONCLUSIONS: In addition to impacts on economic well being, women's empowerment and intimate partner violence, interventions addressing the economic and social vulnerability of women may contribute to reductions in HIV risk behavior

Voice and Agency: Empowering women and girls for shared prosperity

This document presents Voice and Agency: Empowering women and girls for shared prosperity is a major new report by the World Bank that shines a spotlight on the value of voice and agency, the patterns of constraints that limit their realization, and the associated costs, not only to individual women but to their families, communities, and societies. It highlights promising policies and interventions, and it identifies priority areas where further research and more and better data and evidence are needed. Underlining that agency has both intrinsic and instrumental, concrete value, this report puts advancing women's voice and agency squarely on the international development agenda

Patient and health service delay in pulmonary tuberculosis patients attending a referral hospital: a cross-sectional study

BACKGROUND: Delays in diagnosis and initiation of effective treatment increase morbidity and mortality from tuberculosis as well as the risk of transmission in the community. The aim of this study was to determine the time taken for patients later confirmed as having TB to present with symptoms to the first health provider (patient delay) and the time taken between the first health care visit and initiation of tuberculosis treatment (health service delay). Factors relating to these 'delays' were analyzed. METHODS: A cross-sectional survey, of 231 newly diagnosed smear-positive tuberculosis patients was conducted in Mulago National referral Hospital Kampala, from January to May 2002. Socio-demographic, lifestyle and health seeking factors were evaluated for their association with patient delay (>2 weeks) and health service delay (>4 weeks), using odds ratios with 95% confidence intervals (CI) including multivariate logistic regression. RESULTS: The median total delay to treatment initiation was 12 weeks. Patients often presented to drug shops or pharmacies (39.4%) and private clinics (36.8%) more commonly than government health units (14%) as initial contacts. Several independent predictors of 'patient delay' were identified: being hospitalized (odds ratio [0R] = 0.32; 95% CI: 0.12–0.80), daily alcohol consumption (OR = 3.7; CI: 1.57–9.76), subsistence farming (OR = 4.70; CI: 1.67–13.22), and perception of smoking as a cause of TB (OR = 5.54; CI: 2.26–13.58). Independent predictors of 'health service delay' were: >2 health seeking encounters per month (OR = 2.74; CI: 1.10–6.83), and medical expenditure on TB related symptoms >29 US dollars (OR = 3.88; CI: 1.19–12.62). Perceived TB stigma and education status was not associated with either form of delay. CONCLUSION: Delay in diagnosis of TB is prolonged at the referral centre with a significant proportion of Health service delay. More specific and effective health education of the general public on tuberculosis and seeking of appropriate medical consultation is likely to improve case detection. Certain specific groups require further attention. Alcoholics and subsistence farmers should be targeted to improve accessibility to TB treatment. Continuing medical education about TB management procedures for health providers and improvement in the capacity of TB control services should be undertaken

Treatment delay among tuberculosis patients in Tanzania: Data from the FIDELIS Initiative

<p>Abstract</p> <p>Background</p> <p>Several FIDELIS projects (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) in Tanzania were conducted by the National Tuberculosis and Leprosy Programme (NTLP) during the years 2004-2008 to strengthen diagnostic and treatment services. These projects collected information on <it>treatment delay </it>and some of it was available for research purposes. With this database our objective was to assess the duration and determinants of treatment delay among new smear positive pulmonary tuberculosis (TB) patients in FIDELIS projects, and to compare delay according to provider visited prior to diagnosis.</p> <p>Methods</p> <p>Treatment delay among new smear positive TB patients was recorded for each patient at treatment initiation and this information was available and fairly complete in 6 out of 57 districts with FIDELIS projects enrolling patients between 2004 and 2007; other districts had discarded their forms at the time of analysis. It was analysed as a cross sectional study.</p> <p>Results</p> <p>We included 1161 cases, 10% of all patients recruited in the FIDELIS projects in Tanzania. Median delay was 12 weeks. The median duration of cough, weight loss and haemoptysis was 12, 8 and 3 weeks, respectively. Compared to Hai district Handeni had patients with longer delays and Mbozi had patients with shorter delays. Urban and rural patients reported similar delays. Patients aged 15-24 years and patients of 65 years or older had longer delays. Patients reporting contact with traditional healers before diagnosis had a median delay of 15 weeks compared to 12 weeks among those who did not. Patients with dyspnoea and with diarrhoea had longer delays.</p> <p>Conclusion</p> <p>In this patient sample in Tanzania half of the new smear positive pulmonary tuberculosis patients had a treatment delay longer than 12 weeks. Delay was similar in men and women and among urban and rural patients, but longer in the young and older age groups. Patients using traditional healers had a 25% longer median delay.</p

Delayed treatment of tuberculosis patients in rural areas of Yogyakarta province, Indonesia

<p>Abstract</p> <p>Background</p> <p>In year 2000, the entire population in Indonesia was 201 million and 57.6 percent of that was living in rural areas. This paper reports analyses that address to what extent the rural structure influence the way TB patients seek care prior to diagnosis by a DOTS facility.</p> <p>Methods</p> <p>We documented healthcare utilization pattern of smear positive TB patients prior to diagnosis and treatment by DOTS services (health centre, chest clinic, public and private hospital) in Yogyakarta province. We calculated the delay in treatment as the number of weeks between the onset of symptoms and the start of DOTS treatment. Statistical analysis was carried out with Epi Info version 3.3 (October 5, 2004).</p> <p>Results</p> <p>The only factor which was significantly associated with total delay was urban-rural setting (p = < 0.0001). The median total delay for TB patients in urban districts was 8 (1^stQuartile = 4; 3^rdQuartile = 12) weeks compared to 12 (1^stQuartile = 7; 3^rdQuartile = 23) weeks for patients in rural districts. Multivariate analysis suggested no confounding between individual factors and urban-rural setting remained as the main factor for total delay (p = < 0.0001). Primary health centre was the first choice provider for most (38.7%) of these TB patients. Urban-rural setting was also the only factor which was significantly associated with choice of first provider (p = 0.03).</p> <p>Conclusion</p> <p>Improving access to DOTS services in rural areas is an area of vital importance in aiming to make progress toward achieving TB control targets in Indonesia.</p

Reconciling research and implementation in micro health insurance experiments in India: study protocol for a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Microinsurance or Community-Based Health Insurance is a promising healthcare financing mechanism, which is increasingly applied to aid rural poor persons in low-income countries. Robust empirical evidence on the causal relations between Community-Based Health Insurance and healthcare utilisation, financial protection and other areas is scarce and necessary. This paper contains a discussion of the research design of three Cluster Randomised Controlled Trials in India to measure the impact of Community-Based Health Insurance on several outcomes.</p> <p>Methods/Design</p> <p>Each trial sets up a Community-Based Health Insurance scheme among a group of micro-finance affiliate families. Villages are grouped into clusters which are congruous with pre-existing social groupings. These clusters are randomly assigned to one of three waves of implementation, ensuring the entire population is offered Community-Based Health Insurance by the end of the experiment. Each wave of treatment is preceded by a round of mixed methods evaluation, with quantitative, qualitative and spatial evidence on impact collected. Improving upon practices in published Cluster Randomised Controlled Trial literature, we detail how research design decisions have ensured that both the households offered insurance and the implementers of the Community-Based Health Insurance scheme operate in an environment replicating a non-experimental implementation.</p> <p>Discussion</p> <p>When a Cluster Randomised Controlled Trial involves randomizing within a community, generating adequate and valid conclusions requires that the research design must be made congruous with social structures within the target population, to ensure that such trials are conducted in an implementing environment which is a suitable analogue to that of a non-experimental implementing environment.</p

Detection of pulmonary tuberculosis among patients with cough attending outpatient departments in Dar Es Salaam, Tanzania: does duration of cough matter?

According to WHO estimates, tuberculosis case detection rate in Tanzania is less than 50% and this poses a major challenge to control tuberculosis in the country. Currently, one of the defining criteria for suspecting tuberculosis is cough for two weeks or more. We wanted to find out whether the prevalence of tuberculosis was different in patients who reported cough for two weeks or more, compared to patients with cough for less than two weeks. We conducted a cross sectional study in six health facilities in Dar es Salaam, between September and October 2007. All patients aged five years and above with cough were screened for pulmonary tuberculosis (PTB) by smear microscopy. Patients were divided into two groups, those who coughed for less than two weeks (<2 wks) and those who coughed for two weeks or more (> or = 2 wks). A total of 65,530 patients attended outpatients department (OPD). Out of these, 2274 (3.5%) patients reported cough. Among patients who reported cough, 2214 (97.4%) remembered their cough duration. One thousand nine hundred and seventy three patients (89.1%) coughed for >/= 2 wks as compared to 241 (10.9%) patients who coughed for <2 wks. Of those who coughed for two weeks or more, 250 (12.7%) had smear positive PTB, and of those who had coughed for less than two weeks, 21 (8.7%) had smear positive PTB. There was no statistically significant difference in prevalence of smear positive tuberculosis among the two groups (Pearson Chi-Square 3.2; p = 0.074). Detection of smear positive PTB among patients who coughed for less than two weeks was as high as for those who coughed for two weeks or more

Journeys to tuberculosis treatment: a qualitative study of patients, families and communities in Jogjakarta, Indonesia

<p>Abstract</p> <p>Background</p> <p>Many tuberculosis (TB) patients in Indonesia are diagnosed late. We seek to document patient journeys toward TB diagnosis and treatment and factors that influence health care seeking behavior.</p> <p>Methods</p> <p>TB patients in Jogjakarta municipality (urban) and Kulon Progo district (rural) were recruited from health care facilities participating in the DOTS strategy and health care facilities not participating in the DOTS strategy, using purposive sampling methods. Data were collected through in-depth interviews with TB patients and members of their family and through Focus Group Discussions (FGD) with community members.</p> <p>Results</p> <p>In total, 67 TB patients and 22 family members were interviewed and 6 FGDs were performed. According to their care seeking behavior patients were categorized into National TB program's (NTP) dream cases (18%), 'slow-but-sure patients' (34%), 'shopaholics' (45%), and the NTP's nightmare case (3%). Care seeking behavior patterns did not seem to be influenced by gender, place of residence and educational level. Factors that influenced care seeking behavior include income and advice from household members or friends. Family members based their recommendation on previous experience and affordability. FGD results suggest that the majority of people in the urban area preferred the hospital or chest clinic for diagnosis and treatment of TB whereas in the rural area private practitioners were preferred. Knowledge about TB treatment being free of charge was better in the urban area. Many community members from the rural area doubted whether TB treatment would be available free of charge.</p> <p>Conclusion</p> <p>Most TB patients took over a month to reach a DOTS facility after symptoms appeared and had consulted a number of providers. Their income and advice from household members and friends were factors that influenced their care seeking behavior most.</p