Health systems performance in sub-Saharan Africa: Governance, outcome and equity

Copyright @ 2011 Olafsdottir et al.BACKGROUND: The literature on health systems focuses largely on the performance of healthcare systems operationalised around indicators such as hospital beds, maternity care and immunisation coverage. A broader definition of health systems however, needs to include the wider determinants of health including, possibly, governance and its relationship to health and health equity. The aim of this study was to examine the relationship between health systems outcomes and equity, and governance as a part of a process to extend the range of indicators used to assess health systems performance. METHODS: Using cross sectional data from 46 countries in the African region of the World Health Organization, an ecological analysis was conducted to examine the relationship between governance and health systems performance. The data were analysed using multiple linear regression and a standard progressive modelling procedure. The under-five mortality rate (U5MR) was used as the health outcome measure and the ratio of U5MR in the wealthiest and poorest quintiles was used as the measure of health equity. Governance was measured using two contextually relevant indices developed by the Mo Ibrahim Foundation. RESULTS: Governance was strongly associated with U5MR and moderately associated with the U5MR quintile ratio. After controlling for possible confounding by healthcare, finance, education, and water and sanitation, governance remained significantly associated with U5MR. Governance was not, however, significantly associated with equity in U5MR outcomes. CONCLUSION: This study suggests that the quality of governance may be an important structural determinant of health systems performance, and could be an indicator to be monitored. The association suggests there might be a causal relationship. However, the cross-sectional design, the level of missing data, and the small sample size, forces tentative conclusions. Further research will be needed to assess the causal relationship, and its generalizability beyond U5MR as a health outcome measure, as well as the geographical generalizability of the results

Governance and health systems performance: Exploring the association and pathways

This thesis was submitted for the degree of Doctor of Public Health and awarded by Brunel University.There has been an increase in empirical evidence indicating an association between governance and health systems, suggesting that better governed countries tend to have healthier populations with better performing health systems. This is an important finding, as it could point to structural public health interventions having a greater impact on health systems performance than individually targeted interventions. This doctoral thesis in public health (DrPH) from Brunel University is a compilation of three independent research projects undertaken under different settings, converging in the examination of the relationship between governance and health systems. The first project was a study conducted in the African region of the World Health Organization with the aim of understanding how and to what extent measures of governance are statistically correlated with performance of health systems as measured by a key health outcome: the under-five child mortality. The second project was a case study from a high income country in Europe during the period in which it went through an economic meltdown, the focus being a qualitative analysis of the extent to which the response to economic crisis influenced public health policy making and short term performance of the health system. The third project was a policy analysis carried out in an upper middle income country in Asia and the focus was to examine how the long history of health financing reform has influenced the performance of the health system. All research projects indicate an association between governance and health systems and the case studies provide empirical evidence of how health systems are affected by governance quality. The African study shows a statistically positive relationship between governance indicators and health outcomes, suggesting better governed countries to have lower child mortality. The European and the Asian cases suggest accountability, responsiveness, transparency and fair partnership to be important governance qualities for successful policy making and reforms. This evidence could be of use to current and future policy makers and others with the authority to configure and implement new public health policies. It indicates the importance of comprehensive analytical work prior to policy making with easy access to documents and fair participation with all stakeholders to increase the probability of reaching consensus oriented policy proposals followed by successful implementations. The main contribution of this thesis is to provide evidence through robust statistical/ qualitative analysis around the association between governance and health systems in countries at all income levels. The originality is located in the breadth (three different settings) as well as depth (three distinct, robust methods) of this kind of research. The congruence of findings regardless of study locations, the outcome measures used or types of methods applied have added to the growing evidence that there is a strong correlation between governance and health systems performance. This increased knowledge provides policy makers with additional evidence which can be applied to develop and improve governance with the aim of allocating public resources more efficiently and equitably. However, further research is required on governance and its link to health systems, inter alia how health equity is affected by selective partnership in the decision making processes and how political ideologies influence governance practices

Smábörnin með snjalltækin: aðgangur barnanna og viðhorf foreldra

Miðlanotkun spannar sjónvarpsáhorf, tölvuleiki, netnotkun og snjalltækjanotkun. Í ljósi tækniþróunar er mikilvægt að rannsaka miðlanotkun barna allt niður í nokkurra mánaða aldur en það hefur ekki verið gert á Íslandi hingað til. Markmið rannsóknarinnar sem hér er lýst var að gefa yfirlit yfir miðlanotkun barna á Íslandi á aldrinum 0–8 ára og viðhorf foreldra til notkunarinnar. Hér er um fyrsta yfirlit að ræða. Tekið var lagskipt, handahófskennt úrtak 2000 barna á þessum aldri af öllu landinu úr Þjóðskrá, netföng fundust hjá foreldrum 1448 barna (72,4%) og óskað var eftir að þeir svöruðu rafrænum spurningalista að fyrirmynd Sænsku fjölmiðlanefndarinnar. Gild svör bárust frá foreldrum 860 barna sem er 59,4% þátttökuhlutfall en vegna affalla í upphafi er ekki hægt að líta svo á að niðurstöður hafi alhæfingargildi. Niðurstöðurnar gefa þó nokkurt yfirlit, en þær benda til þess að þegar fimm ára aldri hefur verið náð aukist líkur á að börnin eigi sín eigin tæki til miðlanotkunar, sérstaklega spjaldtölvur. Hins vegar deila börn oft snjalltækjum með öðrum í fjölskyldunni, t.a.m. er því svo farið með 62% barna í aldurshópnum 2–4 ára en í þessum aldurshópi notar 71% spjaldtölvu einhvern tíma. Allra yngstu börnin (0–1 árs) nota netið að nokkru marki (4% daglega) en um 80% þess aldurshóps nota netið aldrei. Foreldrar eru oft með börnunum við miðlanotkun en samveran minnkar með hækkandi aldri barnanna. Sjónvarpsáhorf er algeng miðlanotkun meðal 5–8 ára og reglur foreldra eru rýmri um hana en aðra notkun. Sumir foreldrar hafa engar reglur um miðlanotkun en mikill meirihluti þeirra telur að foreldrar beri mesta ábyrgð þegar kemur að því að vernda börn við miðlanotkun. Niðurstöður eru nokkuð í samræmi við niðurstöður úr rannsóknum Sænsku fjölmiðlanefndarinnar. Taka má undir niðurstöður fyrri rannsókna um að samvera foreldra og barna við miðlanotkun sé mikilvæg og draga má þá ályktun að foreldrar viðurkenni mikilvægt hlutverk sitt þegar kemur að miðlanotkun barna.The need has grown for research on the media use of the youngest children with the ever increasing role of internet connected devices in the daily lives of people during the last years. Smartphones and tablets have become common and the tablets are preferred by little fingers. The aim of this study was to provide an overview of the media use of 0-to-8-year-olds in Iceland and their parents’ attitudes towards the use and various aspects of it. A stratified, random sample of 2000 children in this age span from the whole country was the basis for the study. E-mail addresses were found for parents of 1448 children and they were contacted with an introductory letter and a request to fill in a webquestionnaire based on the Swedish Media Council’s questionnaire used since 2010 (Statistics Sweden, 2015). The response rate of those who received the questionnaire was 59.4%, with 860 valid responses. The results suggest that the likelihood of ownership of different devices for media use is higher from the age of 5. This is evident in the case of smartphones and tablets, as a quarter of 5-8y have their own smartphone and/or a tablet. In the age group 2-4y, 10% have their own tablet but 62% share such a device with others in the family, and 56% of 0-1y share a tablet with others in their family. The tablet is most often used for listening to music and watching videos and films. In the age group 0-1y, one third uses the tablet at some point. In the age group 2-4y, this percentage is 71%, and 92% in the age group 5-8y. The most popular activity is watching a movie or a TV show, as over 90% of 2-8y do that at some point, and 62% of 0-1y. Three quarters of the youngest children (0-1y) never use the internet but 4% in this age group use it daily. A small percentage of the children are heavy users according to the definition of the Swedish Media Council of using a medium for three hours or more daily. Two percent of 5-8y play computer games for three or more hours daily and 2% of 2-4y use the internet for three or more hours daily. The children’s parents quite often stay with the children when they use different media. The parents’ presence seems to decrease with age as parents of 60% of the children in the youngest age group (0-1y) are present when their children watch TV shows or films, while the corresponding percentage for 2-4y is 48% and for 5-8y 28%. Watching TV/films is a popular media use for children 5-8y and parents’ rules on this are not as strict as for other media use. Some parents have no rules on media use but a large majority believes that parents are responsible for protecting children regarding media use. The results of this study are quite similar to those from Sweden (Swedish Media Council). The conclusion strengthens results from previous studies on the importance of parents and children being together using media and that parents seem to accept their important role regarding their children’s media use.Peer Reviewe

The accuracy of the National Economic Institute‘s forecasts 1981-2002

The National Economic Institute in Iceland was a government institute responsible for producing and publishing a national economic forecast. The institute was closed in 2002. This paper measures the accuracy of the institute's forecasts from 1981-2002. The paper measures the accuracy of the GDP forecast, private consumption, investment, imports and exports of goods and services.Economic forecast, forecast error, root mean square error,

New collective bargaining contracts and gender wage differentials

The paper measures the gender wage differentials among members of the Icelandic public sector union federation Association of Academics (BHM). The collective bargaining agremeents of the member unions have changed dramatically during the last 15 years while the agreements have also been decentralized. The paper shows that although the gender wage differential has fallen from 1994 to 2007 it is still significant. The base wage gender wage differential is smaller than the gender wage differential when it comes to total earnings.gender wage differential, public sector

Volunteer Muscle Activity in Dynamic Events. Input Data for Human Body Models.

<p>Human body models (HBMs) are virtual human surrogates used to predict kinematic and injury responses during motor vehicle crashes. In recent years, active musculature has been incorporated into HBMs for enhanced biofidelity in simulated emergency scenarios, in particular low-severity crashes and pre-crash situations, where occupant responses are influenced by muscle tension. Development and validation of HBMs that simulate neuromuscular control requires information on muscle activation patterns and contraction levels for different loading levels and directions. This information can be acquired by measuring muscle activity in volunteers with electromyography in replicated pre-crash events. This thesis investigates occupant responses in various pre-crash type braking scenarios and multidirectional perturbations.</p> <p>Muscle activity was measured in volunteers in the following scenarios; maximum voluntary braking, autonomous braking with standard seatbelt, autonomous braking with reversible pre-tensioner activated 200 ms before braking, and seated perturbation in multiple directions without restraint. Muscle activity and forward displacement during autonomous braking was influenced by type of restraint system and role (passenger vs. driver). Pre-tensioning the seatbelt caused decreased forward displacement as well as increased startle like muscle activity in some volunteers. Active HBMs that model the startle reflex can elucidate its effect on injury risk in the crash phase. The difference in posture between drivers and passengers resulted in decreased upper extremity and increased lower back muscle activity for passengers and more forward displacement. Active HBMs validated against the data presented here can be used to further assess the difference between the two occupant roles and to aid the optimisation of safety systems for each group. The spatial tuning patterns generated from multidirectional perturbation showed variable activation amplitudes and preferred directions for the neck muscles. Implementing muscle and direction specific activation schemes in active HBMs might result in better prediction of the head and neck responses.</p> <p>The research outcomes provide data sets for active HBM validation in pre-crash braking events and the development and validation of omnidirectional models. Further studies that identify occupant muscle responses are needed. Measuring muscle activity during a pre-crash steering manoeuvre or during a realistic visual threat to identify the muscle responses following a startle reflex would support the advancement of future omnidirectional models and startle reflex control methods.</p

Initial Clinical Referral Standards after Newborn Screening for Congenital Hypothyroidism: Final Report of the UK Newborn Screening Programme Centre Expert Working Group and Systematic Evidence Review 2010-2011.

Background In April 2010, the Initial Clinical Referral Standards (ICR) for Congenital Hypothyroidism (CHT) Expert Working Group was convened as a sub-group of the Joint Standing Committee for Congenital Hypothyroidism (CHT JSC) to review and revise the UK National Screening Programme Initial Clinical Referral Standards after Newborn Screening for Congenital Hypothyroidism. The work commenced with a systematic review of the published evidence undertaken by Dr R Knowles and Ms F Olafsdottir. The Expert Working Group reviewed and recommended revisions to the existing (2005) UKNSPC standards and guidelines to support confirmatory diagnosis and initial management for babies in whom CHT is suspected. This included a review of current CHT screening policy and UK performance against national standards and European standards and guidelines. The Expert Working Group, chaired by Dr T Cheetham (Consultant Paediatric Endocrinologist), met on four occasions between July 2010 and September 2011 to review and revise the referral standards. Scope of the review To support the review process with evidence review and expert consensus where published evidence is lacking, focusing on the following topic areas: • Screening test performance and indications for referral • Diagnostic schedule for confirmatory diagnosis of CHT • Initial treatment and frequency of follow up to the point of diagnosis or definitive management • Communication flows • Communication with parents Public Consultation A public consultation was carried out in May/June 2012 and subsequent changes to the standards on the basis of the responses are included in this final version of the report. Summary and Recommendations The subgroup’s final recommendations were endorsed by the Joint Standing Committee and Blood Spot Advisory Group (BSAG) and submitted to the Fetal Maternal and Child Health Subgroup of the National Screening Committee (NSC) for approval of changes to current screening policy and standards. This final report presents the revised standards, screening protocol and diagnostic protocol developed by the Expert Working Group and finalised after public consultation, as well as the evidence basis for the revised standards and guidelines

Interactions between boldness, foraging performance and behavioural plasticity across social contexts

Boldness, the tendency to be explorative, risk prone and proactive, often varies consistently between individuals. An individual’s position on the boldness–shyness continuum hasmany implications. Bold individuals may outperform shyer conspecifics during foraging as they cover more ground, accumulate informationmore rapidly andmake more frequent food discoveries. Individual variation in boldness may also affect behavioural plasticity across environmental contexts, as the time to process new information, the ability to locate and memorise resources and the time and ability to apply prior information in a novel context all differ between individuals. The primary aim of the current study was to examine plasticity in, and covariation between, boldness, foraging speed and foraging accuracy across social foraging contexts.We showed that the stickleback that were shyest when foraging alone became relatively boldest when foraging in a social context and also delayed their entry to a known food patch the most in the presence of conspecifics. These results support the assertion that shyer foragers are more reactive to social cues and add to current knowledge of how an individual’s position on the boldness–shyness continuum may correlate to foraging task performance and behavioural plasticity. We conclude that the correlation between boldness and behavioural plasticity may have broad relevance as the ability to adjust or retain behaviours in changing social environments could often have consequences for fitness