How the health-seeking behaviour of pregnant women affects neonatal outcomes: findings of system dynamics modelling in Pakistan

Background: Limited studies have explored how health-seeking behaviour during pregnancy through to delivery affect neonatal outcomes. We modelled health-seeking behaviour across urban and rural settings in Pakistan, where poor neonatal outcomes persist with wide disparities. Methods and findings: A system dynamics model was developed and parameterised. Following validation tests, the model was used to determine neonatal mortality for pregnant women considering their decisions to access, refuse and switch antenatal care services in four provider sectors: public, private, traditional and charitable. Four health-seeking scenarios were tested across different pregnancy trimesters. Health-seeking behaviour in different subgroups by geographical locations and social network effect was modelled. The largest reduction in neonatal mortality was achieved with antenatal care provided by skilled providers in public, private or charitable sectors, combined with the use of institutional delivery. Women’s social networks had strong influences on if, when and where to seek care. Interventions by Lady Health Workers had a minimal impact on health-seeking behaviour and neonatal outcomes after trimester 1. Optimal benefits were achieved for urban women when antenatal care was accessed within trimester 2, but for rural women within trimester 1. Antenatal care access delayed to trimester 3 had no protective impact on neonatal mortality. Conclusions: System dynamics modelling enables capturing the complexity of health-seeking behaviours and impact on outcomes, informing intervention design, implementation of targeted policies and uptake of services specific to urban/rural settings considering structural enablers/barriers to access, cultural contexts and strong social network influences

Expansion of health insurance in Moldova and associated improvements in access and reductions in direct payments

Background Moldova is the poorest country in Europe. Economic constraints mean that Moldova faces challenges in protecting individuals from excessive costs, improving population health and securing health system sustainability. The Moldovan government has introduced a state benefit package and expanded health insurance coverage to reduce the burden of healthcare costs for citizens. This study examines the effects of expanded health insurance by examining factors associated with health insurance coverage, likelihood of incurring out-of-pocket (OOP) payments for medicines or services, and the likelihood of forgoing healthcare when unwell. Methods Using publically available databases and the annual Moldova Household Budgetary Survey, we examine trends in health system financing, healthcare utilisation, health insurance coverage, and costs incurred by individuals for the years 2006-2012. We perform logistic regression to assess the likelihood of having health insurance, incurring a cost for healthcare, and forgoing healthcare when ill, controlling for socio-economic and demographic covariates. Findings Private expenditure accounted for 55.5% of total health expenditures in 2012. 83.2% of private health expenditures is OOP payments – especially for medicines. Healthcare utilisation is inline with EU averages of 6.93 outpatient visits per person. Being uninsured is associated with groups of those aged 25-49 years, the self-employed, unpaid family workers, and the unemployed, although we find lower likelihood of being uninsured for some of these groups over time. Overtime, the likelihood of OOP for medicines increased (OR=1.422 in 2012 compared to 2006), but fell for healthcare services (OR=0.873 in 2012 compared to 2006). No insurance and being older and male, was associated with increased likelihood of forgoing healthcare when sick, but we found the likelihood of forgoing healthcare to be increasing over time (OR=1.295 in 2012 compared to 2009). Interpretation Moldova has achieved improvements in health insurance coverage with reductions in OOP for services, which are modest but are eroded by increasing likelihood of OOP for medicines. Insurance coverage was an important determinant for healthcare costs incurred by patients and patients forgoing healthcare. Improvements notwithstanding, there is an unfinished agenda of attaining universal health coverage in Moldova to protect individuals from healthcare costs

Financing essential HIV services: a new economic agenda.

Anna Vassall and colleagues discuss the need for, and challenges facing, innovative and sustainable financing of the HIV response. Please see later in the article for the Editors' Summary

Analysis of National Cancer Control Programmes in Europe

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Systematic analysis of funding awarded for norovirus research to institutions in the United Kingdom, 1997-2010.

OBJECTIVES: Norovirus infections pose great economic and disease burden to health systems around the world. This study quantifies the investments in norovirus research awarded to UK institutions over a 14-year time period. DESIGN: A systematic analysis of public and philanthropic infectious disease research investments awarded to UK institutions between 1997 and 2010. PARTICIPANTS: None SETTING: UK institutions carrying out infectious disease research. MAIN OUTCOME MEASURES: Total funding for infectious disease research, total funding for norovirus research, position of norovirus research along the R&D value chain. RESULTS: The total dataset consisted of 6165 studies with sum funding of £2.6 billion. Twelve norovirus studies were identified with a total funding of £5.1 million, 0.2% of the total dataset. Of these, eight were categorized as pre-clinical, three as intervention studies and one as implementation research. Median funding was £200,620. CONCLUSIONS: Research funding for norovirus infections in the UK appears to be unacceptably low, given the burden of disease and disability produced by these infections. There is a clear need for new research initiatives along the R&D value chain: from pre-clinical through to implementation research, including trials to assess cost-effectiveness of infection control policies as well as clinical, public health and environmental interventions in hospitals, congregate settings and in the community

Systematic analysis of funding awarded for norovirus research to institutions in the United Kingdom, 1997-2010

Objectives:Norovirus infections pose great economic and disease burden to health systems around the world. This study quantifies the investments in norovirus research awarded to UK institutions over a 14-year time period.Design:A systematic analysis of public and philanthropic infectious disease research investments awarded to UK institutions between 1997 and 2010.Participants:NoneSetting:UK institutions carrying out infectious disease research.Main outcome measures:Total funding for infectious disease research, total funding for norovirus research, position of norovirus research along the R&amp;D value chain.Results:The total dataset consisted of 6165 studies with sum funding of £2.6 billion. Twelve norovirus studies were identified with a total funding of £5.1 million, 0.2% of the total dataset. Of these, eight were categorized as pre-clinical, three as intervention studies and one as implementation research. Median funding was £200,620.Conclusions:Research funding for norovirus infections in the UK appears to be unacceptably low, given the burden of disease and disability produced by these infections. There is a clear need for new research initiatives along the R&amp;D value chain: from pre-clinical through to implementation research, including trials to assess cost-effectiveness of infection control policies as well as clinical, public health and environmental interventions in hospitals, congregate settings and in the community.</p

Variability in interpretation of chest radiographs among Russian clinicians and implications for screening programmes: observational study.

OBJECTIVE: To determine variability in interpretation of chest radiographs among tuberculosis specialists, radiologists, and respiratory specialists. DESIGN: Observational study. SETTING: Tuberculosis and respiratory disease services, Samara region, Russian Federation. PARTICIPANTS: 101 clinicians involved in the diagnosis and management of pulmonary tuberculosis and respiratory diseases. MAIN OUTCOME MEASURES: Interobserver and intraobserver agreement on the interpretation of 50 digital chest radiographs, using a scale of poor to very good agreement (kappa coefficient: < or = 0.20 poor, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 good, and 0.81-1.00 very good). RESULTS: Agreement on the presence or absence of an abnormality was fair only (kappa = 0.380, 95% confidence interval 0.376 to 0.384), moderate for localisation of the abnormality (0.448, 0.444 to 0.452), and fair for a diagnosis of tuberculosis (0.387, 0.382 to 0.391). The highest levels of agreement were among radiologists. Level of experience (years of work in the specialty) influenced agreement on presence of abnormalities and cavities. Levels of intraobserver agreement were fair. CONCLUSIONS: Population screening for tuberculosis in Russia may be less than optimal owing to limited agreement on interpretation of chest radiographs, and may have implications for radiological screening programmes in other countries

Differences in research funding for women scientists: a systematic comparison of UK investments in global infectious disease research during 1997–2010

Objectives: There has not previously been a systematic comparison of awards for research funding in infectious diseases by sex. We investigated funding awards to UK institutions for all infectious disease research from 1997 to 2010, across disease categories and along the research and development continuum. Design: Systematic comparison. Methods: Data were obtained from several sources for awards from the period 1997 to 2010 and each study assigned to—disease categories; type of science (preclinical, phases I–III trials, product development, implementation research); categories of funding organisation. Fold differences and statistical analysis were used to compare total investment, study numbers, mean grant and median grant between men and women. Results: 6052 studies were included in the final analysis, comprising 4357 grants (72%) awarded to men and 1695 grants (28%) awarded to women, totalling £2.274 billion. Of this, men received £1.786 billion (78.5%) and women £488 million (21.5%). The median value of award was greater for men (£179 389; IQR £59 146–£371 977) than women (£125 556; IQR £30 982–£261 834). Awards were greater for male principal investigators (PIs) across all infectious disease systems, excepting neurological infections and sexually transmitted infections. The proportion of total funding awarded to women ranged from 14.3% in 1998 to 26.8% in 2009 (mean 21.4%), and was lowest for preclinical research at 18.2% (£285.5 million of £1.573 billion) and highest for operational research at 30.9% (£151.4 million of £489.7 million). Conclusions: There are consistent differences in funding received by men and women PIs: women have fewer funded studies and receive less funding in absolute and in relative terms; the median funding awarded to women is lower across most infectious disease areas, by funder, and type of science. These differences remain broadly unchanged over the 14-year study period

Review of experience of family medicine in Europe and Central Asia (Vol. 3): Bosnia and Herzegovina case study

This report summarizes the findings of four case studies that review the experience of family medicine in Europe and Central Asia (ECA) Region. It is part of a study comprising five volumes that review the experience of family medicine in four countries in ECA--Armenia, Bosnia and Herzegovina, Kyrgyz Republic and Moldova. The report reviews the experience, draws lessons, and establishes an evidence base for detailed analysis. The study presents best practices for policy dialogue and future investments by the World Bank and other financial institutions. The detailed case studies compare these countries and draw common themes and issues. Comparisons are made with best-developed or existing models in the OECD and other countries in the Europe and Central Asia Region that have already undertaken family medicine reform

Systematic analysis of funding awarded for mycology research to institutions in the UK, 1997–2010

Objectives: Fungal infections cause significant global morbidity and mortality. We have previously described the UK investments in global infectious disease research, and here our objective is to describe the investments awarded to UK institutions for mycology research and outline potential funding gaps in the UK portfolio. Design: Systematic analysis. Setting: UK institutions carrying out infectious disease research. Primary and secondary outcome measures Primary outcome is the amount of funding and number of studies related to mycology research. Secondary outcomes are describing the investments made to specific fungal pathogens and diseases, and also the type of science along the R&D value chain. Methods: We systematically searched databases and websites for information on research studies from public and philanthropic funding institutions awarded between 1997 and 2010, and highlighted the mycology-related projects. Results: Of 6165 funded studies, we identified 171 studies related to mycology (total investment £48.4 million, 1.9% of all infection research, with mean annual funding £3.5 million). Studies related to global health represented 5.1% of this funding (£2.4 million, compared with 35.6% of all infectious diseases). Leading funders were the Biotechnology and Biological Sciences Research Council (£14.8 million, 30.5%) and Wellcome Trust (£12.0 million, 24.7%). Preclinical studies received £42.2 million (87.3%), with clinical trials, intervention studies and implementation research in total receiving £6.2 million (12.7%). By institution, University of Aberdeen received most funding (£16.9 million, 35%). Studies investigating antifungal resistance received £1.5 million (3.2%). Conclusions: There is little translation of preclinical research into clinical trials or implementation research in spite of substantial disease burden globally, and there are few UK institutions that carry out significant quantities of mycology research of any type. In the context of global health and the burden of disease in low-income countries, more investment is required for mycology research