Mothers and Children: Designing research toward integrated care for both

In this paper we examine pragmatic corollaries to the design and implementation of Millennium Development Goals (MDG) 4 and 5. The first corollary we analyze is how the timeframe imposed on the MDGs affects choices about how to implement health care interventions to meet those goals, which we look at specifically in terms of the trade-off between strengthening a health care system or increasing mass campaigns. The second corollary is that, in the allocation of resources, those choices must often be made between providing health care interventions for certain members of the population as opposed to others. We analyze aspects of these unintentional effects of the MDGs, and then offer a model for designing research on the provision of maternal and child health that does aim to take them into account

Global Health and the Demands of the Day

We have two goals in this paper: first, to provide a diagnosis of global health and underline some of its blockages; second, to offer an alternative interpretation of what the demands for those in global health may be. The assumption that health is a "good" that requires no further explanation, and that per se it can serve as an actual modus operandi, lays the foundations of the problem. Related blockages ensue and are described using HIV prevention with a focus on vaginal microbicides as a case study. Taking health as a self-evident, and self-explanatory "good" limits other possible goods; and prevents further inquiry into the actual practices of creating good practices and good measures. We propose that to create conditions under which global health could be reconstructed, "problematization" be taken up as a practice, around a series of questions asked in conjunction with those ever-urgent ones of how to ameliorate the condition of living beings

Estimating and Comparing Health and Financial Risk Protection Outcomes in Economic Evaluations

Objectives Improving health and financial risk protection (FRP, the prevention of medical impoverishment) and their distributions is a major objective of national health systems. Explicitly describing FRP and disaggregated (eg, across socioeconomic groups) impact of health interventions in economic evaluations can provide decision makers with a broader set of health and financial outcomes to compare and prioritize interventions against each other. Methods We propose methods to synthesize such a broader set of outcomes by estimating and comparing the distributions in both health and FRP benefits procured by health interventions. We build on benefit-cost analysis frameworks and utility-based models, and we illustrate our methods with the case study of universal public finance (financing by government regardless of whom an intervention is targeting) of disease treatment in a low- and middle-income country setting. Results Two key findings seem to emerge: FRP is critical when diseases are less lethal (eg, case fatality rates <1% or so), and quantitative valuation of inequality aversion across income groups matters greatly. We recommend the use of numerous sensitivity analyses and that all distributional health and financial outcomes be first presented in a disaggregated form (before potential subsequent aggregation). Conclusions Estimation approaches such as the one we propose provide explicit disaggregated considerations of equity, FRP, and poverty impact for the development of health sector policies, with high relevance for population-based preventive measures.publishedVersio

Le don de colostrum en situation de séparation mère-enfant

En 2013, une étude consacrée au colostrum (financée par l’ANR) s’installe à l’hôpital l’Archet à Nice. Les premiers résultats immunologiques et anthropologiques présentés aux professionnels impliqués dans la problématique de la séparation parents/enfant lors d’une naissance prématurée ont favorisé l’élaboration d’un « projet colostrum » concerté entre les services de néonatalogie et de maternité. Un protocole de soin inédit consistant à donner le colostrum de leur mère à des enfants nés en dessous de 32 semaines d’aménorrhée est alors mis en place. Ce don indirect implique l’expression manuelle du premier lait, son transport et parfois sa conservation pour qu’il passe du sein de la mère à la bouche du bébé. Sans recommandations spécifiques au colostrum, les procédures élaborées combinent la nouveauté à l’habituel pour aboutir au basculement du colostrum du domaine de l’alimentaire à celui du traitement.A study was carried out on Colostrum in 2013 (funded by the French National Agency for Research) in the Hospital l’Archet in Nice, France. Preliminary immunological and anthropological data submitted to the staff working on parents/child issues related to premature birth have led to the elaboration of the « Project Colostrum » between neonatal and maternity services. An innovative care protocol has been set up consisting in giving mothers’ colostrum to premature infants born before 32 weeks of amenorrhoea. This donation of colostrum implies manual expressing breast milk, its transport and storage, from the mothers’ breast to the infants’ mouths. In the absence of particular recommendations regarding colostrum, the procedures developed combine novelty and routine procedures, and result in the shifting of colostrum as a food issue to a medical treatment

Impact of measles supplementary immunization activities on reaching children missed by routine programs.

BACKGROUND: Measles supplementary immunization activities (SIAs) are vaccination campaigns that supplement routine vaccination programs with a recommended second dose opportunity to children of different ages regardless of their previous history of measles vaccination. They are conducted every 2-4 years and over a few weeks in many low- and middle-income countries. While SIAs have high vaccination coverage, it is unclear whether they reach the children who miss their routine measles vaccine dose. Determining who is reached by SIAs is vital to understanding their effectiveness, as well as measure progress towards measles control. METHODS: We examined SIAs in low- and middle-income countries from 2000 to 2014 using data from the Demographic and Health Surveys. Conditional on a child's routine measles vaccination status, we examined whether children participated in the most recent measles SIA. RESULTS: The average proportion of zero-dose children (no previous routine measles vaccination defined as no vaccination date before the SIA) reached by SIAs across 14 countries was 66%, ranging from 28% in São Tomé and Príncipe to 91% in Nigeria. However, when also including all children with routine measles vaccination data, this proportion decreased to 12% and to 58% when imputing data for children with vaccination reported by the mother and vaccination marks on the vaccination card across countries. Overall, the proportions of zero-dose children reached by SIAs declined with increasing household wealth. CONCLUSIONS: Some countries appeared to reach a higher proportion of zero-dose children using SIAs than others, with proportions reached varying according to the definition of measles vaccination (e.g., vaccination dates on the vaccination card, vaccination marks on the vaccination card, and/or self-reported data). This suggests that some countries could improve their targeting of SIAs to children who miss other measles vaccine opportunities. Across all countries, SIAs played an important role in reaching children from poor households

Évolution des peuplements issus de feu et de coupe dans la forêt boréale mixte de l'Abitibi

Le milieu scientifique soutient depuis quelques années que les effets de la coupe à blanc pratiquée historiquement et des feux de forêt sont différents et que cela aurait des effets significatifs sur les processus écologiques des écosystèmes forestiers ainsi que sur leur biodiversité. Cependant, bien que ces perturbations puissent créer des structures et des compositions de peuplements très différentes immédiatement après la perturbation, peu de recherches ont évalué la dynamique des peuplements à plus long terme. En Abitibi, dans la sapinière à bouleau blanc de l'Ouest, l'activité forestière a laissé des empreintes sur le paysage forestier qui se caractérisent par une augmentation de la proportion des peuplements feuillus. Ainsi, ce projet cherche vise à savoir si les différences initiales de structure et composition entre des peuplements coupés et brûlés se maintiennent, ou convergent avec le temps. Pour ce faire, des peuplements de plus de 30 ans issus de feu et des premières coupes totales de la région ont été analysés. En outre, on cherchait à savoir si le type de dépôt-drainage influence différemment les peuplements selon la perturbation d'origine. En utilisant les données des réseaux de placettes échantillons temporaires et permanentes (PET et PEP) du 3ème inventaire forestier décennal pour les régions écologiques 5a et 5b, nous avons sélectionné 56 brûlis et 43 coupes totales qui ont entre 27 à 52 ans. De plus, 41 peuplements matures, qui constituent, en quelque sorte, un état de référence, ont aussi été sélectionnés. Ces 140 peuplements se situent sur des sites mésiques fertiles ou mésiques pauvres. Plusieurs attributs de structure (densité, surface terrière, variabilité des DHP, hauteur dominante, surface terrière de chicots, etc.) ainsi que l'importance relative (IR) des espèces principales ont été déterminés. Les analyses statistiques ont été effectuées à l'aide de modèles linéaires généralisés. Nos résultats démontrent que les différences entre les attributs étudiés de peuplements issus de coupe ou de feu s'estompent généralement avec le temps. Cependant, des attributs tels que la variabilité des DHP (indice de Shannon) ou la hauteur dominante des peuplements coupés (1,69 et 14,36 m respectivement) ou brûlés (1,71 et 14,46 m) dans la fenêtre temporelle de l'étude sont encore significativement inférieurs aux peuplements matures de référence (2,06 et 17,22 m). La composition semble converger plus lentement que la structure puisque la diminution des différences dans le temps est moins prononcée. Contrairement à nos attentes, plus de 40 ans après perturbation, l'IR de l'épinette noire est de 40% dans des peuplements issus de coupe alors que dans les feux elle n'est que de 20%. En outre, l'IR combinée du pin gris et du peuplier monte à 35% dans les feux contre 13% dans les coupes. La compréhension de la dynamique des peuplements après coupe totale (et incendies forestiers) à long-terme reste encore fragmentaire. Une analyse plus approfondie est nécessaire pour mieux cerner cette dynamique afin d'élaborer des stratégies d'aménagement adaptées au contexte abitibien.\ud ______________________________________________________________________________ \ud MOTS-CLÉS DE L’AUTEUR : Coupe totale, Feu de forêt, Forêt boréale mixte, Structure, Composition

Comparing the health and social protection effects of measles vaccination strategies in Ethiopia: An extended cost-effectiveness analysis

AbstractVaccination coverage rates often mask wide variation in access, uptake, and cost of providing vaccination. Financial incentives have been effective at creating demand for social services in a variety of settings. Using methods of extended cost-effectiveness analysis, we compare the health and economic implications of three different vaccine delivery strategies for measles vaccination in Ethiopia: i) routine immunization, ii) routine immunization with financial incentives, and iii) mass campaigns, known as supplemental immunization activities (SIAs). We examine annual birth cohorts of almost 3,000,000 births over a ten year period, exploring variation in these outcomes based on economic status to understand how various options may improve equity. SIAs naturally achieve higher levels of vaccine coverage, but at higher costs. Routine immunization combined with financial incentives bolsters demand among more economically vulnerable households. The relative appeal of routine immunization with financial incentives and SIAs will depend on the policy environment, including short-term financial limitations, time horizons, and the types of outcomes that are desired. While the impact of financial incentives has been more thoroughly studied in other policy arenas, such as education, consideration of this approach alongside standard vaccination models such as SIAs is timely given the dialog around measles eradication

Active case finding in tuberculosis-affected households: time to scale up

In 2017, 10 million people developed tuberculosis, of whom approximately 4 million were not diagnosed, treated, or notified to national tuberculosis programmes (NTP).1 Of the remaining 6 million, many experienced substantial delays in accessing and receiving appropriate care.1 This unacceptable situation leads to unnecessary disability and loss of life, and impedes tuberculosis control because of onward transmission at a household and community level. To rectify these shortcomings and eliminate tuberculosis, new strategies are urgently required to enhance tuberculosis case detection

Defining Pathways and Trade-offs Toward Universal Health Coverage Comment on “Ethical Perspective: Five Unacceptable Trade-offs on the Path to Universal Health Coverage”

The World Health Organization’s (WHO’s) World Health Report 2010, “Health systems financing, the path to universal coverage,” promoted universal health coverage (UHC) as an aspirational objective for country health systems. Yet, in addition to the dimensions of services and coverage, distribution of coverage in the population, and financial risk protection highlighted by the report, the consideration of the budget constraint should be further strengthened in the ensuing debate on resource allocation toward UHC. Beyond the substantial financial constraints faced by low- and middle-income countries, additional considerations, such as the geographical context, the underlying country infrastructure, and the architecture of health systems, determine the feasibility, effectiveness, quality and cost of healthcare delivery. Therefore, increased production and use of local evidence tied to the criteria of health benefits, equity, financial risk protection, and costs accompanying health delivery are needed so that to highlight pathways and acceptable trade-offs toward UHC

Inequalities in utilization of maternal and child health services in Ethiopia: the role of primary health care

Background: Health systems aim to narrow inequality in access to health care across socioeconomic groups and area of residency. However, in low-income countries, studies are lacking that systematically monitor and evaluate health programs with regard to their effect on specific inequalities. We aimed to measure changes in inequality in access to maternal and child health (MCH) interventions and the effect of Primary Health Care (PHC) facilities expansion on the inequality in access to care in Ethiopia. Methods: The Demographic and Health Survey datasets from Ethiopia (2005 and 2011) were used. We calculated changes in utilization of MCH interventions and child morbidity. Concentration and horizontal inequity indices were estimated. Decomposition analysis was used to calculate the contribution of each determinant to the concentration index. Results: Between 2005 and 2011, improvements in aggregate coverage have been observed for MCH interventions in Ethiopia. Wealth-related inequality has remained persistently high in all surveys. Socioeconomic factors were the main predictors of differences in maternal and child health services utilization and child health outcome. Utilization of primary care facilities for selected maternal and child health interventions have shown marked pro-poor improvement over the period 2005–2011. Conclusions: Our findings suggest that expansion of PHC facilities in Ethiopia might have an important role in narrowing the urban-rural and rich-poor gaps in health service utilization for selected MCH interventions.publishedVersio