Tackling the drivers of child undernutrition in developing countries : What works and how should interventions be designed?

OBJECTIVE: The present paper presents a synthesis of available evidence to support action on the interventions that can effectively address the main drivers of child undernutrition in developing countries. It also discusses how interventions should be designed and identifies policy-relevant areas for further research. DESIGN: A structured literature review of fifty-eight controlled evaluations and studies in developing countries were selected because they are methodologically sound, recent (reported within the past 10 years), report on nutritional status, cover a wide range of interventions and are implemented by a range of different agencies. SETTING: Indirect interventions in developing countries, which address the underlying and basic causes of child undernutrition and can potentially be implemented in the short to medium term. SUBJECTS: Children under 5 years of age and their mothers across a range of developing countries. RESULTS: Evidence has now accumulated to guide action on a range of indirect interventions that can reduce child undernutrition, but for all these interventions context is all-important. There is less evidence on how these interventions can be effectively implemented on a large scale. CONCLUSIONS: Efforts should be directed towards improving implementation of effective interventions on a large scale. Donors need to keep commitments both in dollar terms and in terms of the Paris Declaration so that the push for improved nutrition does not become donor driven. At the country level, there is a need for enabling governance structures, institutions and evidence-based decision making. Within countries there is a need for well-trained personnel with delegated authority, accountable to local people. It is essential for chains of accountability to be transparent and for active involvement of households in decision-making processes

Estimating demand pressures arising from need for social services for older people

The twelve years preceding the introduction of the community care reforms in 1993/4 saw an increased demand for health and social services generated by the increase in numbers of older people (particularly the over 85s) and reflected in the rapid growth of residential and nursing home places over a twelve year period (from 224,000 in 1983 to 427,000 in 1994). While the move into the residential and nursing home sector was partly driven by the perverse incentives offered by social security in the early 1980s, it may also have reflected a real increase in the levels of dependency experienced by older people coming into contact with the services during the period. This has fuelled concern about rising costs. However, there are competing forecasts of how big a burden the costs of care will be. One of the difficulties is in determining how far the burden will fall on statutory services or formal services (provided by either the statutory or independent sectors) and how far the pool of informal carers will be large enough to maintain the level of care which it provides currently. The Institute of Actuaries published an influential paper in 1993 (Nuttall et al, 1993) suggesting that the current cost of informal caring based on a rate of £7 per hour could be estimated at £33.9 billion. The House of Commons Health Committee (1996) took evidence during 1995 and 1996 and concluded that the gloomiest forecasts were unfounded and that radical action was not needed in the immediate future. Nevertheless, whatever the predictions for the medium and long term, concerns have been raised with regard to current capacities to meet demand. The community care changes resulting from the Act were funded by a transfer, Special Transitional Grant (STG), to the local authorities with which to meet their new responsibilities. There has been a continuing debate as to whether the STG and the SSA allocations have been sufficient to enable them to do this. The Association of Directors of Social Services and the Association of Metropolitan Authorities (now subsumed into the Association of Local Government) have repeatedly called for a review of the current funding of community care saying they are unable to meet the full needs of dependent people (Community Care, 1996, 1997a).elderly, social services

Economic Analysis of Cost-Effectiveness of Community Engagement to Improve Health

Liberty of association is one of the building blocks of a democratic society, and presumes that community engagement in a democratic society is universally a good thing. This presumption is not subject to economic analysis, but the issue considered here is whether community engagement is a better vehicle for improving the community’s health than another approach. The problems of applying the standard framework of economic evaluation to consider this issue include: multiple perspectives and time frames; identifying and costing activities and specifically the costs of volunteer time; identifying and measuring benefits; identifying comparator communities; how the intervention interacts with the community and therefore identifying end gainers and losers and eventually how the former might compensate the latter; attribution of any changes in community (health) to the approaches and methods of community engagement (CE); quantification across the whole range of community engagement. We consider three possible ways to apply the tools of economic appraisal to assess community engagement, these being: developing a typology; relying just on effectiveness data from the literature and guesstimating costs; and developing a scenario based on partial information about both costs and benefits. We assess the impact of community engagement on health and health behaviour; the contribution of community engagement to supporting social networks and social capital formation; and other impacts specific to a particular situation, including collective and ideological outcomes (whether of citizenship, obedience or political literacy). We conclude with a set of questions to ask of any CE intervention.

Missing Millions and Measuring Progress towards the Millenium Development Goals with a focus on Central Asian States

BackgroundIn developing countries, population estimates and assessments of progress towards the Millenium Development Goals are based increasingly on household surveys.  It is not recognised that they are inappropriate for obtaining information about the poorest of the poor..  This is because they, typically, omit by design: those not in households because they are homeless; those who are in institutions; and mobile, nomadic or pastoralist populations.  In addition, in practice, because they are difficult to reach, household surveys will typically under-represent: those in fragile, disjointed or multiple occupancy households; those in urban slums, and may omit certain areas of a country deemed to pose a security risk. Those six sub-groups constitute a pretty comprehensive ostensive definition of the ‘poorest of the poor’.MethodsThis paper documents these omissions in general, drawing on worldwide literature about the theory and practice fo implementing censuses and household surveys; and shows how substantial proportions are missing from both censuses and the sample frames of surveys.ResultsThis paper suggests that between 300 and 350 million will effectively be missed worldwide from the sampling frames of such surveys and from most censuses.  The impact on the health MDGs is illustrated for the five republics of the former Soviet Union making up Central Asia: Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and UzbekistanConclusionsIt is impossible to assess progress towards or away from the MDGS in both the Central Asian Republics and worldwide.  It is urgent to find solutions to the problem of the ‘missing ‘ poor population sub-groups

The need for general medical services: a literature review

General Medical Services (GMS) are provided mainly through Family Practices, on a demand led basis: that is, there is no cash limit expect for certain specified selected services such as Practice Nurses etc. Nevertheless, since 1948, the Medical Practices Committee (MPC) have influenced the delivery of GMS through a system of allowances for areas designated as under-doctored; and, of course, there are deprivation payments (mostly in urban areas) and the rural practice allowance. However, there have been questions about the extent to which the provision of GMS - and specifically the distribution of General Practitioners (GPs) between areas - is equitable. The purpose of this review of the literature on the need for GMS was to provide a background to discussions about ways in which the current methods being used to guide the MPC decisions about the distribution of GPs could be improved. In the first section, this context and the current situation are briefly described. Before discussing the determinants of consultations workload, we show, in the second section, how the proportions actually getting as far as a consultation are considerably smaller than the proportions claiming at any one time to be ill, and set out a crude model of the pathways to a consultation, which sets the framework for the subsequent review. We also discuss the controversies over the measurement of workload itself: ideally, we want to be able to measure ‘real’ utilisation including both the length and complexity of the consultation, whilst controlling for variations between general practitioners. The factors influencing the demand for primary care are considered in the third section. Demand for primary care consultations is influenced by certain socio-economic factors (age, sex, housing tenure, unemployment, social class, family structure/marital status, rural/urban residence, ethnic group) which are related to the prevalence and incidence of illness. Less reliable, but equally important determinants of demand, are the pathways to primary care charted by individuals on the basis of the patient's perceptions of illness and illness behaviour which are set out in section two. Other factors affecting the demand for primary care consultations are considered in the fourth section under the headings of accessibility and organisation of primary care. Accessibility whether in terms of cultural, financial; or physical barriers does make a difference: proximity to a primary care facility increases consultation patterns whereas distance decreases consultation rates. Appointment systems do influence patient demand: in particular follow-up appointments may increase because of the transfer of services from secondary to primary care. Second, there is no conclusive evidence that list size affects GMS utilisation although large list sizes may restrict the amount of time available for individual patients: in some circumstances this may reduce the quality of care provided. Third, preventative services, whilst not always utilised by those most at risk, generate significant added workload. Fourth, the 1990 contract has increased administrative burdens and, by virtue of the availability of clinics, generated added medical workload. In the fifth section, supply issues are briefly considered. Patients do attend A&E departments - especially when they are close - for conditions often more appropriate for primary care but the reasons for this behaviour are complex and difficult to reverse. There are statistical techniques available for adjusting for supply, although this will always be a complicated procedure in this area unless analysis is restricted to individual data. The characteristics of high attenders or those demonstrating increased SPCRs can be summarised • Frequent attendance is often associated with a defined illness whether physical or mental, and this is reflected in a substantial number of GP initiated follow up appointments. • High users perceive themselves to be ill and are anxious or fearful about their symptoms but have faith in the GP rather than a belief in self care. • Increased GMS utilisation is associated with: families with high attendance rates; social classes 4 and 5; ethnic minorities; women; the unemployed; mobile populations; and people from deprived areas. Patients whose response to illness is less likely to be to consult a GP are less prone to worry about symptoms; feel in greater control of their lives; are more sceptical of the effectiveness of the GP's treatment, sometimes as a result of an unsatisfactory past or family experience; and are more prone to use and believe in self care and rely on/possess social/friendship networks. There are therefore a wide range of factors associated with consultations. The few multivariate analyses that have been carried out are discussed in the sixth section: their results demonstrate that both self-reported ill-health and socio-economic deprivation independently affect the level of consultations. There has therefore been a considerable amount of research; in the concluding section we argue that more of the same will not help. The problem is that the different data sets available - although leading to very similar conclusions - each only provide a partial picture. In order to improve on existing evidence, we need data on consultations from a representative sample of practices over a period where data is recorded on both the length and markers for complexity, whilst the patients on their lists are asked to complete a brief questionnaire about both their self-perceived health and their socio-economic status. Nevertheless, despite these problems - which are not, in principle, any more severe than those confronted in other areas where resource allocation formulae have been developed - there is a consensus about the factors influencing the need for GMS (even though there are queries about the consultation measure itself): • first, self-reported ill-health does reflect real morbidity as well as trivial complaints and is a powerful determinant of the propensity to consult; and • second, there are a range of socio-economic factors which are associated with the likelihood of consultation over and above ill-health whether measured in terms of self-report or ‘objectively’. On this basis, a formula could therefore be developed incorporating both a morbidity variable and a combination of socio-economic variables.primary care, general medical services, socio-economic factors

Towards locally based resource allocation in the NHS

In a health care system where resources are scarce and the principle of equity is of central concern, mechanisms for the appropriate allocation of resources based on the notion of relating resource use to some concept of need are essential. Two key issues raised in the UK government’s White Paper The New NHS: modern, dependable are the ability first to define health care budgets at a local level and second to integrate budgets to encompass all relevant aspects of health care delivery. This paper considers the theoretical and practical implications of devolving NHS budgets to primary care groups. The paper advocates the development of a patient-based survey of all NHS health care utilization, which could serve as the basis for integrated global budgets for use at a local level.resource allocation; health care budgets; primary care; health need; general practice

Monitoring the Performance of Educational Programmes in Developing Countries

Teaching/Communication/Extension/Profession,

Finding and Counting Difficult to Reach Population Groups in the UK (and other Developed Countries)

Background Censuses are meant to provide a complete count and basic information about all households and individuals in a country. After decades of complacency, it has begun to be realised that this can no longer be guaranteed. Several of the presentations at the Edinburgh in March 2018 demonstrated methods which the ONS were developing to resolve many of the problems; but those methods do not solve the problem of those who, for a variety of reasons, cannot or do not want to be counted. Objectives This paper sets out to document the possible size of the ‘hidden’ populations in the UK and demonstrate that they are predominantly poor. Methods (including data) Estimates of the numbers are provided (globally and in the UK) in difficult-to-reach categories: homeless/street children, care homes/hospitals, military, prisons, refugees and illegal immigrants, gypsies/travellers, urban slums. With the exception of the military, the majority in each group are poor. Findings The paper then reviews approaches to counting and describing the various categories: • grosso modo, those in institutions can already be headcounted but apart from relevant institutional status, gender and perhaps age, we have no other information about them; but the main problem is that, in many cases, there is potential double counting with their (temporarily) broken household. • for both Refugees/ Illegal immigrants and Gypsy/ Traveller Population, the main problem is the reluctance of the former to complete forms or be interviewed and of the latter to acknowledge their own ethnic identity • in high rise blocks where lifts are not always working, there will certainly be some unsurveyed and uncensored people; and the Grenfell Towers experience shows that there is not always a secure count of the numbers Conclusions The issue of ‘hidden’ or missing populations in the UK has to be taken much more seriously