Health systems analysis of eye care services in Zambia: evaluating progress towards VISION 2020 goals.

BACKGROUND: VISION 2020 is a global initiative launched in 1999 to eliminate avoidable blindness by 2020. The objective of this study was to undertake a situation analysis of the Zambian eye health system and assess VISION 2020 process indicators on human resources, equipment and infrastructure. METHODS: All eye health care providers were surveyed to determine location, financing sources, human resources and equipment. Key informants were interviewed regarding levels of service provision, management and leadership in the sector. Policy papers were reviewed. A health system dynamics framework was used to analyse findings. RESULTS: During 2011, 74 facilities provided eye care in Zambia; 39% were public, 37% private for-profit and 24% owned by Non-Governmental Organizations. Private facilities were solely located in major cities. A total of 191 people worked in eye care; 18 of these were ophthalmologists and eight cataract surgeons, equivalent to 0.34 and 0.15 per 250,000 population, respectively. VISION 2020 targets for inpatient beds and surgical theatres were met in six out of nine provinces, but human resources and spectacles manufacturing workshops were below target in every province. Inequalities in service provision between urban and rural areas were substantial. CONCLUSION: Shortage and maldistribution of human resources, lack of routine monitoring and inadequate financing mechanisms are the root causes of underperformance in the Zambian eye health system, which hinder the ability to achieve the VISION 2020 goals. We recommend that all VISION 2020 process indicators are evaluated simultaneously as these are not individually useful for monitoring progress

A cross sectional study investigating the association between exposure to food outlets and childhood obesity in Leeds, UK

Abstract Background: Current UK policy in relation to the influence of the 'food environment' on childhood obesity appears to be driven largely on assumptions or speculations because empirical evidence is lacking and findings from studies are inconsistent. The aim of this study was to investigate the number of food outlets and the proximity of food outlets in the same sample of children, without solely focusing on fast food. Methods: Cross sectional study over 3 years (n = 13,291 data aggregated). Body mass index (BMI) was calculated for each participant, overweight and obesity were defined as having a BMI >85 th (sBMI 1.04) and 95 th (sBMI 1.64) percentiles respectively (UK90 growth charts). Home and school neighbourhoods were defined as circular buffers with a 2 km Euclidean radius, centred on these locations. Commuting routes were calculated using the shortest straight line distance, with a 2 km buffer to capture varying routes. Data on food outlet locations was sourced from Leeds City Council covering the study area and mapped against postcode. Food outlets were categorised into three groups, supermarkets, takeaway and retail. Proximity to the nearest food outlet in the home and school environmental domain was also investigated. Age, gender, ethnicity and deprivation (IDACI) were included as covariates in all models. Results: There is no evidence of an association between the number of food outlets and childhood obesity in any of these environments; Home Q4 vs. Q1 OR = 1.11 (95% CI = 0.95-1.30); School Q4 vs. Q1 OR = 1.00 (95% CI 0.87 -1.16); commute Q4 vs. Q1 OR = 0.1.00 (95% CI 0.83 -1.20). Similarly there is no evidence of an association between the proximity to the nearest food outlet and childhood obesity in the home (OR = 0.77 [95% CI = 0.61 -0.98]) or the school (OR = 1.01 [95% CI 0.84 -1.23]) environment. Conclusions: This study provides little support for the notion that exposure to food outlets in the home, school and commuting neighbourhoods increase the risk of obesity in children. It seems that the evidence is not well placed to support Governmental interventions/recommendations currently being proposed and that policy makers should approach policies designed to limit food outlets with caution

Haemophilus influenzae type b vaccine in low- and middle- income countries: Impact, costs and incremental cost-utility.

Haemophilus influenzae type b (Hib) is an infectious bacterium transmitted from person to person through close contact. Hib can cause meningitis, pneumonia and a number of rarer forms of disease, primarily in children less than five years. Hib conjugate vaccines became available during the early 1990s and high-income countries quickly introduced this vaccine into their routine programmes and have now achieved a near disappearance of Hib disease. However, relatively high vaccine prices and uncertainties about Hib disease burden led to a slow uptake in low- and middle-income countries. The aim of this PhD is to fill gaps in knowledge about the value of Hib vaccination, in terms of whether or not it is a cost-effective intervention in low- and middle-income countries. Moreover, since economic evaluation involves gathering evidence about numerous criteria that may be considered in isolation by policy makers, such as vaccine efficacy, disease burden, meningitis sequelae prevalence and cold chain expansion costs, specific objectives are also to address some of the unanswered questions about key inputs and determinants of cost-effectiveness. The framework of the PhD is shaped around a decision-analytic model designed to estimate the cost-utility of Hib vaccination. The methodology, collection and analysis of data inputs needed to populate the model represent a number of sub-studies, which are all contributions to new evidence. These include a meta-analysis of Hib vaccine efficacy, calculation of Disability Adjusted Life Years due to Hib disease, estimation of treatment costs of Hib disease, assessment of productivity costs due to meningitis sequelae, and calculation of systems costs of introducing Hib vaccine. Case studies from two countries are included in the sub-studies; productivity costs of meningitis sequelae are investigated in Senegal and systems costs of Hib vaccine introduction are estimated in Ethiopia. Cost-utility results generated from the decision-analytic model are presented for two low-income countries; India and Uzbekistan, and one middle-income country; Belarus. This PhD thesis is the first attempt to combine evidence on disease burden, costs and impact of Hib vaccine across multiple countries using a consistent framework and comparable input parameters. As a result, new insights into the relative cost-utility in countries with different economic and epidemiological circumstances are obtained

Opportunities and challenges for implementing cost accounting systems in the Kenyan health system.

Low- and middle-income countries need to sustain efficiency and equity in health financing on their way to universal health care coverage. However, systems meant to generate quality economic information are often deficient in such settings. We assessed the feasibility of streamlining cost accounting systems within the Kenyan health sector to illustrate the pragmatic challenges and opportunities. We reviewed policy documents, and conducted field observations and semi-structured interviews with key informants in the health sector. We used an adapted Human, Organization and Technology fit (HOT-fit) framework to analyze the components and standards of a cost accounting system. Among the opportunities for a viable cost accounting system, we identified a supportive broad policy environment, political will, presence of a national data reporting architecture, good implementation experience with electronic medical records systems, and the availability of patient clinical and resource use data. However, several practical issues need to be considered in the design of the system, including the lack of a framework to guide the costing process, the lack of long-term investment, the lack of appropriate incentives for ground-level staff, and a risk of overburdening the current health management information system. To facilitate the implementation of cost accounting into the health sector, the design of any proposed system needs to remain simple and attuned to the local context

SCENE: A novel model for engaging underserved and underrepresented audiences in informal science learning activities

Inequitable access to science, technology, engineering, arts and mathematics (STEAM) has been explored by multiple studies which have shown that some publics are underserved by existing informal educational and cultural provision, and under-represented in related study choices and careers. Informal science learning (ISL) and public engagement with research activities (such as science festivals) tend to attract audiences which are largely white, middle class and already engaged with STEM. This article describe the development of an engagement approach and model through a story-based festival (SMASHfestUK) which was specifically designed to attract new and diverse audiences, including Black and mixed-heritage families, and families living with socio-economic disadvantage. The festival was delivered on five annual occasions, each co-designed with a wide selection of stakeholders, including audiences, researchers, performers, institutions and organizations, and considered as an iterative prototype

Household experience and costs of seeking measles vaccination in rural Guinea-Bissau.

OBJECTIVES: Children younger than 12 months of age are eligible for childhood vaccines through the public health system in Guinea-Bissau. To limit open vial wastage, a restrictive vial opening policy has been implemented; 10-dose measles vaccine vials are only opened if six or more children aged 9-11 months are present at the vaccination post. Consequently, mothers who bring their child for measles vaccination can be told to return another day. We aimed to describe the household experience and estimate household costs of seeking measles vaccination in rural Guinea-Bissau. METHODS: Within a national sample of village clusters under demographic surveillance, we interviewed mothers of children aged 9-21 months about their experience with seeking measles vaccination. From information about time and money spent, we calculated household costs of seeking measles vaccination. RESULTS: We interviewed mothers of 1308 children of whom 1043 (80%) had sought measles vaccination at least once. Measles vaccination coverage was 70% (910/1308). Coverage decreased with increasing distance to the health centre. On average, mothers who had taken their child for vaccination took their child 1.4 times. Mean costs of achieving 70% coverage were 2.04 USD (SD 3.86) per child taken for vaccination. Half of the mothers spent more than 2 h seeking vaccination and 11% spent money on transportation. CONCLUSIONS: We found several indications of missed opportunities for measles vaccination resulting in suboptimal coverage. The household costs comprised 3.3% of the average monthly income and should be taken into account when assessing the costs of delivering vaccinations

Screening for breast cancer : medicalization, visualization and the embodied experience

Women’s perspectives on breast screening (mammography and breast awareness) were explored in interviews with midlife women sampled for diversity of background and health experience. Attending mammography screening was considered a social obligation despite women’s fears and experiences of discomfort. Women gave considerable legitimacy to mammography visualizations of the breast, and the expert interpretation of these. In comparison, women lacked confidence in breast awareness practices, directly comparing their sensory capabilities with those of the mammogram, although mammography screening did not substitute breast awareness in a straightforward way. The authors argue that reliance on visualizing technology may create a fragmented sense of the body, separating the at risk breast from embodied experience

The value of demonstration projects for new interventions: The case of human papillomavirus vaccine introduction in low- and middle-income countries.

Demonstration projects or pilots of new public health interventions aim to build learning and capacity to inform country-wide implementation. Authors examined the value of HPV vaccination demonstration projects and initial national programmes in low-income and lower-middle-income countries, including potential drawbacks and how value for national scale-up might be increased. Data from a systematic review and key informant interviews, analyzed thematically, included 55 demonstration projects and 8 national programmes implemented between 2007-2015 (89 years' experience). Initial demonstration projects quickly provided consistent lessons. Value would increase if projects were designed to inform sustainable national scale-up. Well-designed projects can test multiple delivery strategies, implementation for challenging areas and populations, and integration with national systems. Introduction of vaccines or other health interventions, particularly those involving new target groups or delivery strategies, needs flexible funding approaches to address specific questions of scalability and sustainability, including learning lessons through phased national expansion