Health sector decentralization and Indonesia ' s nutrition programs : opportunities and challenges

This policy concept paper is intended to assist the center in navigating the tension between opportunities and challenges as activities are adapted to the decentralized national nutrition policy, and to help guide districts and provinces in the conduct o f locally appropriate nutrition programs. The paper synthesizes the findings of an extensive study undertaken by the World Bank with a summary of the results, while the conclusions are discussed in detail in the four annexes. It begins with a review of the accomplishments and remaining nutrition challenges for Indonesia. It then turns to look at the regional diversity in Indonesia ' s nutrition challenges and asks which type of nutrition programs are most cost-effective. The paper concludes with an assessment of the existing institutional arrangement for nutrition service delivery, and discusses steps Indonesia can take to further improve population nutrition and health. The annexes provide extensive data and analysis to shed light on the opportunities and challenges in the new institutional environment.Health Monitoring & Evaluation,Nutrition,Early Child and Children ' s Health,Population Policies,Rural Development Knowledge & Information Systems

The Cochrane Collaboration: institutional analysis of a knowledge commons

Cochrane is an international network that produces and updates new knowledge through systematic reviews for the health sector. Knowledge is a shared resource, and can be viewed as a commons. As Cochrane has been in existence for 25 years, we used Elinor Ostrom's theory of the commons and Institutional Analysis and Development Framework to appraise the organisation. Our aim was to provide insight into one particular knowledge commons, and to reflect on how this analysis may help Cochrane and its funders improve their strategy and development. An assessment of Cochrane product showed extensive production of systematic reviews, although assuring consistent quality of these reviews is an enduring challenge; there is some restriction of access to the reviews, open access is not yet implemented; and, while permanence of the record is an emerging problem, it has not yet been widely discussed. The assessment of the process showed that the resource, community, and rules-in-use are complex, vary between different groups within Cochrane, and are not well understood. Many of the rules have been informal, and the underlying ethos of volunteerism where reviews get done are important features and constraints to the organisation. Like all collective efforts, Cochrane is subject to collective action problems, particularly free-riding and variable commitment, and the under-production of public goods and internal processes, such as surveillance of product quality and procedures for transparent resolution of conflicts

GPU Accelerated Simulation of Transport Systems

Computer modelling and simulation of road networks are a vital tool used to evaluate, design and manage road network infrastructure. Road network simulations are however computationally expensive, with simulation runtime imposing limits on the scale and quantity of simulations performed within a reasonable time frame. This thesis examines the appropriateness of many-core processing architectures (such as GPUs) for the acceleration of microscopic and macroscopic road network simulation, and the potential impact on the choice of modelling approach. Fine-grained agent-based microscopic simulations of individual vehicles are parallelised using GPUs, achieving high performance through a novel graph-based communication strategy for data-parallel simulations. A minimal benchmark model and scalable road network are defined and used experimentally to evaluate performance compared to Aimsun, a commercial simulation tool for multi-core processors. Performance improvements of up to 67x are demonstrated for large scale simulations. High-level macroscopic simulations model network flow rather than individual vehicles. Although less computationally demanding than microscopic models, simulation runtimes can still be significant, often due to the calculation of many shortest paths. A novel Many-Source Shortest Path (MSSP) algorithm is proposed to concurrently find multiple shortest paths through sparse transport networks using GPUs. This is embedded within a commercial multi-core CPU macroscopic simulation tool, SATURN, and the performance evaluated on large-scale real-world road networks, demonstrating assignment performance improvements of up to 8.6x when comparing multi-processor GPU and CPU implementations. Finally, the impact of the performance improvements to both modelling techniques are evaluated using a common benchmark model and the relative improvements demonstrated by the benchmarking of each approach using different transport networks. These results suggest that GPUs will allow modellers to shift towards using finer-grained simulations for a broader range of modelling tasks

Paradox lost:disappearing female job satisfaction

The greater job satisfaction reported by female workers represents a puzzle given, on average, their worse labour market outcomes. Using the original data source of Clark (1997), we show that over the last two decades the female satisfaction gap has largely vanished. This reflects a strong secular decline in female job satisfaction. This decline happened for younger women in the 1990s as they aged and because of new female workers in more recent years that have lower job satisfaction than their early 1990s peers. Decompositions make clear that the decline does not reflect deteriorating job characteristics for women but rather their increasingly harsh evaluation of jobs characteristics. These findings fit with the suggestion that women in the early 1990s had a gap between their labour market expectations and actual experience that has since closed and that the gender satisfaction gap has vanished as a consequence

Public funding of health at the district level in Indonesia after decentralization – sources, flows and contradictions

<p>Abstract</p> <p>Background</p> <p>During the Suharto era public funding of health in Indonesia was low and the health services were tightly controlled by the central government; district health staff had practically no discretion over expenditure. Following the downfall of President Suharto there was a radical political, administrative and fiscal decentralization with delivery of services becoming the responsibility of district governments. In addition, public funding for health services more than doubled between 2001 and 2006. It was widely expected that services would improve as district governments now had both more adequate funds and the responsibility for services. To date there has been little improvement in services. Understanding why services have not improved requires careful study of what is happening at the district level.</p> <p>Methods</p> <p>We collected information on public expenditure on health services for the fiscal year 2006 in 15 districts in Java, Indonesia from the district health offices and district hospitals. Data obtained in the districts were collected by three teams, one for each province. Information on district government revenues were obtained from district public expenditure databases maintained by the World Bank using data from the Ministry of Finance.</p> <p>Results</p> <p>The public expenditure information collected in 15 districts as part of this study indicates district governments are reliant on the central government for as much as 90% of their revenue; that approximately half public expenditure on health is at the district level; that at least 40% of district level public expenditure on health is for personnel, almost all of them permanent civil servants; and that districts may have discretion over less than one-third of district public expenditure on health; the extent of discretion over spending is much higher in district hospitals than in the district health office and health centers. There is considerable variation between districts.</p> <p>Conclusion</p> <p>In contrast to the promise of decentralization there has been little increase in the potential for discretion at the district level in managing public funds for health – this is likely to be an important reason for the lack of improvement in publicly funded health services. Key decisions about money are still made by the central government, and no one is held accountable for the performance of the sector – the district blames the center and the central ministries (and their ministers) are not accountable to district populations.</p

Making a success of providing NHS Health Checks in community pharmacies across the Tees Valley: a qualitative study

In England and Wales, the Department of Health introduced a primary prevention programme, NHS Health Checks, to provide screening for cardiovascular risk amongst people aged 40-74. The aim of this programme is to offer treatment and advice to those identified with an increased risk of cardiovascular diseases (CVD).The North East of England has some of the highest rates of CVD in the UK and prevention is therefore a priority. NHS Tees funded this programme of work under the local branding of Healthy Heart Checks (HHC). These were initially implemented principally through GP practices from October 2008 but, in order to mitigate the possibility that some hard to reach communities would be reluctant to engage with some primary care settings, plans were also developed to deliver the programme through workplace settings and through community pharmacies. This paper reports specifically on the findings from the evaluation in respect of the setting up of HHCs in community pharmacies and aims to offer some lessons for other service settings where this option is seen as a way of providing low threshold services which will minimise inequalities in intervention uptake

Why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in West Java Province, Indonesia

<p>Abstract</p> <p>Background</p> <p>Trained birth attendants at delivery are important for preventing both maternal and newborn deaths. West Java is one of the provinces on Java Island, Indonesia, where many women still deliver at home and without the assistance of trained birth attendants. This study aims to explore the perspectives of community members and health workers about the use of delivery care services in six villages of West Java Province.</p> <p>Methods</p> <p>A qualitative study using focus group discussions (FGDs) and in-depth interviews was conducted in six villages of three districts in West Java Province from March to July 2009. Twenty FGDs and 165 in-depth interviews were conducted involving a total of 295 participants representing mothers, fathers, health care providers, traditional birth attendants and community leaders. The FGD and in-depth interview guidelines included reasons for using a trained or a traditional birth attendant and reasons for having a home or an institutional delivery.</p> <p>Results</p> <p>The use of traditional birth attendants and home delivery were preferable for some community members despite the availability of the village midwife in the village. Physical distance and financial limitations were two major constraints that prevented community members from accessing and using trained attendants and institutional deliveries. A number of respondents reported that trained delivery attendants or an institutional delivery were only aimed at women who experienced obstetric complications. The limited availability of health care providers was reported by residents in remote areas. In these settings the village midwife, who was sometimes the only health care provider, frequently travelled out of the village. The community perceived the role of both village midwives and traditional birth attendants as essential for providing maternal and health care services.</p> <p>Conclusions</p> <p>A comprehensive strategy to increase the availability, accessibility, and affordability of delivery care services should be considered in these West Java areas. Health education strategies are required to increase community awareness about the importance of health services along with the existing financing mechanisms for the poor communities. Public health strategies involving traditional birth attendants will be beneficial particularly in remote areas where their services are highly utilized.</p

Lost Voices in Research: Exposing the Gaps in the Mental Capacity Act 2005

Despite laudable intentions, since its inception, the Mental Capacity Act 2005 of England and Wales (MCA) has proved to be a controversial piece of legislation. The majority of legal scholarship has concentrated on the problems created by the Act in relation to the treatment of incapacitated patients. However, there is an additional and somewhat unexplored dimension to the MCA, that of research. We argue here that the research provisions of the MCA are poorly drafted and do not provide an appropriate balance between protection and empowerment. We also assert that contrasting obligations and expectations are placed on different parties in the approval process, which creates a blurred sense of responsibility and a potential chilling effect

Inclusion under the Mental Capacity Act (2005) : a review of research policy guidance and governance structures in England and Wales

Objective: To investigate how people with communication and understanding difficulties, associated with conditions such as dementia, autism and intellectual disability, are represented in research guidance supplementary to the Mental Capacity Act (MCA: 2005) in England and Wales. Methods: A documentary survey was conducted. The sample comprised the MCA Code of Practice (CoP: 2007) and 14 multi-authored advisory documents that were publicly available on the Health Research Authority website. Textual review of key words was conducted followed by summative content analysis. Results: Representation of people with communication and understanding difficulties was confined to procedural information and position statements that focused mainly on risk management and protection. Whilst a need to engage potential participants was recognised, guidance provided was imprecise. Conclusions: Tensions exist between the protection versus empowerment of people with communication and understanding difficulties in research. The development of structured, evidence-based guidance is indicated. Patient or public contribution: People with communication and understanding difficulties and carers participated in a working group to explore, discuss and interpret the findings