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

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 sub-groups by geographic 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 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

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

Working Pape

The role of eLearning in health management and leadership capacity building in health system: a systematic review

Background Health leadership and management are essential for ensuring resilient health systems. Relevant training opportunities are often scarce, and the use of digital education could help address this gap. Our aim was to assess the effectiveness of eLearning for healthcare leadership and management capacity building. Methods We performed a systematic review on the effectiveness of eLearning for health leadership and management training. We also reviewed literature on relevant competencies and training programmes. We conceptualise the role of health leadership and management capacity building in health system strengthening and explore the use of eLearning in this area. Results No evidence was found on the effectiveness of eLearning for health leadership and management capacity guiding. Evidence on health leadership and management education effectiveness in general is scarce and descriptive and reports learning outcomes. We explore how various forms of eLearning can help meet specific requirements of health leadership and management training. Conclusions Literature on the effectiveness of health leadership and management education is scarce. The use of eLearning could support this type of training by making it more accessible and tailored. Future research should be carried out in diverse settings, assume experimental designs, evaluate the use of information technology and report health system outcomes

Investing in emerging infectious diseases: a systematic analysis of UK research

Background: Emerging and infectious diseases threaten health, security, and the global economy. However, little is known about investments in research to tackle outbreaks and innovate new tools for infectious disease control.Methods & Materials: We systematically searched databases and websites for information on research investments for the period 1997-2010. We identified 325,922 studies for screening, included 6,165 studies in the initial analysis, and identified 654 studies on emerging infectious diseases in the final analysis.Results: We identified a total research investment in emerging infectious diseases of £199 million, accounting for 7.7% of a total research investment in infectious diseases of £2.6 billion. In comparison, investment in HIV research amounted to £478 million (18.4% of total investment).Diagnostic tools for control accounted for £9.8 million (4.9%) across 66 studies. Studies assessing therapeutics accounted for £20.0 million (9.9%) across 35 studies. Vaccine research attracted the least funding for tools to tackle emerging infectious diseases, with £11.5 million (5.8%) across 24 studies.Hepatitis C received the most investment with £59.7 million (30.0%), followed by prion research with £33.5 million (16.8%), Campylobacter jejuni with £24.1 million (12.1%), and Helicobacter pylori with £15.1 million (7.6%). Although total influenza investment was £80.1 million, funding specifically for H5N1 influenza virus was £13.7 million (6.9%) and for H1N1 influenza virus was £10.8 million (5.4%).Public funding accounted for £144.0 million (72.3%) across 361 studies with philanthropic funding awarding £40.6 million (20.4%) across 173. Preclinical research attracted the most investment with £142.4 million (71.5%) followed by epidemiological and operational research with £42.1 million (21.2%) and product development research with £12.2 million (6.1%). Phase 1, 2, 3 clinical trials was the least well-funded type of research with £2.5 million (1.2%).Conclusion: Emerging infectious diseases receives small amounts of funding compared to other scientific disciplines, with the exception of HIV. It is essential that we map, monitor and evaluate emerging infectious disease research funding given their importance to global health security

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