 |
Providing high quality accessible information to policy makers and practitioners working in health and development |
Produced by the IDS Health and Development Information team in collaboration with Eldis and the DFID Health Resource Centre Increasing access to health services by poor people Feature: Increasing access to health services by poor people Recommended readings:
Latest additions:
Feature: Increasing access to health services by poor people Increasing the accessibility of health services to poor people requires overcoming the well known obstacles of travel time, convenient hours, and trust. These obstacles differ in importance for urban and rural poor people. Spatial obstacles to care are less important for urban poor people, but convenient hours matter more. In rural areas solutions to travel time bring tradeoffs between more clinics in more locations and better clinics in few places. There are no universal solutions, but there are universal ways of finding them. Solid understanding of how the components of a health system fit together is crucial because access for poor people involves improvement in finance, governance, supply chain, work force deployment, and primary health care delivery. It also requires changes in the information system to make poor people more visible. This means tracking the socioeconomic status of clients served in order to assess whether they are being reached. If poor people were more visible in health system data, one could begin to understand how poverty interacts with epidemiology both in the course of disease, but also in how treatment is sought and complied with. Poverty is defined as a lack of resources. It is experienced as powerlessness, voicelessness, and dependency. The very voicelessness of poor people makes them unlikely stakeholders to push for solutions for their own problems of access. Throughout history, contingency, culture, and chance have sometimes led society at large to address the issue of social protection. Having local stakeholders raising the issue of health care accessibility is a more sustainable approach than when the concerns are raised by distant parties. Recent migration patterns have altered the politics of social protection. These days urban poor people are more visible to the powerful elites and to donors. This raises the importance of solid measurement of where poor people are and what are their barriers to health care access. This feature was written by Dr. David Bishai, from the Johns Hopkins Bloomberg School of Public Health. More information:
Recommended readings 1. Reducing health inequalities in developing countries What does current thinking tell us about trends in health inequalities and methods for reducing such inequalities? This is the central question addressed by D. Gwatkin of the World Bank in an article that draws on a variety of worldwide studies on health inequalities in developing countries. Gwatkin’s article, which makes up a chapter of a book on public health, is divided into four sections. The first provides a brief history of recent trends in concern about health inequalities. The second is a discussion of the concept of health inequalities, while the third summarises what is known about the dimensions and magnitudes of such inequalities. The fourth section presents a comparable summary of current thought about how best to reduce inequalities. The key findings, taken from a number of recent studies, are as follows:
It is now commonly agreed that improvements in public health are not determined solely by improvements in health services. A broader approach is needed that influences development policy more generally and includes interventions in other sectors such as water and sanitation, and conflict resolution. Approaches for tackling inequality in health provision that are proposed in this article are as follows:
Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=11664&type=Document 2. India: equity effects of quality improvements on health service utilization and patient satisfaction in Uttar Pradesh State Uttar Pradesh, with 170 million people is India’s most populous state. Socioeconomic inequalities in health outcomes are large within India overall, but more pronounced in Uttar Pradesh and neighbouring states. This study by the Health, Nutrition, and Population (HNP) Family of the World Bank's Human Development Network, investigates the impact of a health systems development project in Uttar Pradesh, on utilisation of health services and patient satisfaction for the poor and lower caste members. The project began in July 2000, and introduced a range of reforms including management training, new staffing and service patterns, provision of essential drugs, and repair of equipment and facilities. The study finds that there was a consistent increase in mean monthly outpatient visits at all levels of project sites compared to controls, indicating that the project has improved overall utilisation levels. Although patients from the poorest 40 precent of the population increased utilisation at all types of facilities except the women’s hospitals, the wealthiest 40 percent had larger increases at each level of facility. Lower caste members gained at all facilities relative to higher caste members. The project had a significantly positive impact on patient satisfaction at lower levels of facilities but not for patients from the poorest 40 percent. The authors find that patient satisfaction overall improved only at lower level project facilities, not hospitals. The wealthiest group showed gains in satisfaction with every type of facility, and with significantly higher improvements than the poorest group. Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43852&type=Document 3. Protecting the poor against health shocks Ill-health is one of the most serious challenges that many households have to face. This short paper from the Institute of Development Studies provides a background to catastrophic illness, health perceptions, attitudes and beliefs. The authors also consider health related interventions. They stress that in the design of interventions intended to counter health-related shocks, it is important to recognise the variety of existing social mechanisms established to cope with health challenges. The authors discuss how most societies utilise a combination of universal entitlement programmes, targeted benefits and discretionary arrangements to help households cope with major illness, complementing a variety of “informal” community and family-based arrangements. The paper warns that it is dangerous to generalise, but the richer the society, the smaller its structural inequalities and the more sophisticated and stable its institutional arrangements the more likely are universal entitlements to play a significant role. It is highlighted that there are major methodological challenges to be overcome in understanding health shocks. Research in this area entails the development of a range of innovative methodologies, combining quantitative and qualitative data. The design of appropriate support will almost certainly depend to a considerable extent on the existing situation in any given country. It is important for research to explore a wide range of national and local circumstances in order to assess the potential and limitations of different approaches. Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43853&type=Document 4. Health insurance for the poor in India In general, health insurance is not well developed in India. A major part of total health spending in the country takes the form of private, out-of-pocket spending which is clearly regressive in nature. This paper by ICRIER argues that community based health insurance (CBHI) is more suited than alternate arrangements to providing health insurance to the low-income people living in developing countries. The universal health insurance scheme, launched recently by the Prime Minister of India, is only one of the forms that CBHI can take. While analysing the proposed scheme, the authors examine alternate forms of CBHI schemes prevalent in the country. The authors argue that the development of private health insurance markets in the country will not leave the poor unaffected. Insurance sector reform can affect poor people through its effect on the provision of health services (i.e. cost, quality and access) used by the low-income people as well as through its access to financing of health care. The paper explores how insurance sector reforms alter health insurance prospects facing poor people in India, and what changes on the health front affecting the poor have happened or are likely to happen as a result of insurance sector reforms. It is concluded that in the diverse settings of India all forms of CBHI have a role to play and therefore need to be encouraged by the government through appropriate interventions. Formal insurance providers can also be reigned to serve low-income populations. At the same time, developments in formal health insurance markets need to be guided so as to minimise cost escalation of health care provision. [adapted from the author] Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43854&type=Document 5. Urban poverty and health in developing countries This bulletin, published by the Population Reference Bureau, provides a sketch of urban health in developing countries, documenting the intra-urban differences in health for a number of countries and showing how the risks facing the urban poor compare with those facing rural villagers. It begins with an overview of the multiple dimensions of urban poverty and a summary of internationally comparable evidence on the urban health differentials associated with poverty. The author notes that to better understand urban health in developing countries, the situations of the urban poor and near-poor must be distinguished from those of other city residents. Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43850&type=Document Latest additions from the Health systems resource guide 1. Experiences of parliamentary committees on health in promoting health equity in East and Southern Africa Parliamentarians can play a key role in lobbying for health and social issues as part of the legislative process. This EQUINET discussion paper explores the contribution of parliamentary committees in promoting health in 10 countries in the African region.
The study also addresses the challenges facing parliamentary committees such as mechanisms for communication, lack of a clear focus, operational issues and the resources required for the overall execution of duties. Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43829&type=Document 2. Operations manual for delivery of HIV prevention, care and treatment at primary health centres in high-prevalence, resource-constrained settings: edition 1 for fieldtesting and country adaptation This operations manual, published by the World Health Organization, provides guidance on planning and delivering HIV prevention, care, and treatment services at health centres in countries with high HIV prevalence. It provides an operational framework to ensure that HIV services can be provided in an integrated, efficient and quality-assured manner. The manual is based on the public health approach to scaling up HIV services in resource-constrained settings, which includes simple, standardised regimens and formularies; standardised supervision and patient monitoring approaches; as well as integrated delivery of care at primary health centres within a district network. The authors recognise that decentralisation of services to health centre and community level is facilitated with the public health approach. The manual consists of 11 chapters:
This manual is written as a learning aid and job aid for the health centre team, and in particular the health centre manager (often an in-charge nurse). The authors, however, contend that district management teams, which supervise and support health centre services, should also find this manual helpful, as should national Ministries of Health and other partners responsible for planning and supporting the decentralisation of HIV services. Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43764&type=Document 3. The impact of the AIDS pandemic on health services in Africa: evidence from demographic and health surveys This paper, published by the National Bureau of Economic Research, documents the impact of the AIDS crisis on non-AIDS related health services in 14 sub-Saharan African countries. The authors, using multiple waves of Demographic and Health Surveys (DHS) for each country, examine antenatal care, birth deliveries, and rates of immunisation for children born between 1988 and 2005. The authors find deterioration in nearly all of the above dimensions of health care over this period. Using data collected on HIV prevalence in the most recent DHS survey for each country, the authors find that erosion of health services is highly correlated with increases in AIDS prevalence. Consequently, regions of countries that have light AIDS burdens have witnessed small or no declines in health care, using the measures noted above, while those regions currently shouldering the heaviest burdens have seen the largest erosion in treatment for pregnant women and children. Finally, the authors estimate the beginning of the divergence in health services between high and low HIV regions to the mid-1990s. Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43762&type=Document 4. Malaria misdiagnosis in Uganda – implications for policy change This article examines the effectiveness of the current methods for the diagnosis of malaria in Uganda. Diagnosis has mainly been through presumptive management – that is diagnosis on the basis of episodes of fever. However, the authors of this paper argue that while these recommendations are valid, this form of diagnosis has significantly contributed to the over-diagnosis of malaria in all age groups in mid to high transmission areas. While the diagnosis in children under the age of five years old using this method has led to under-diagnosis. The study investigators conducted interviews with patients at 188 facilities and took laboratory samples in order to assess the accuracy of the existing diagnosis. It was found that the overall prevalence of malaria was around 24.2 percent, with a rate of 13.9 percent in adults and 50.5 percent for children under the age of five years old. Furthermore, the use of microscopy was lower than expected in facilities where this diagnostic method was available. In terms of treatment for malaria, 96.2 percent of patients with a positive diagnosis received treatment as well as 47.6 percent of patients with a negative result. In order to address issues pertaining to the misdiagnosis of malaria, the current reliance on the existence of fever should be re-examined. The study authors therefore argue for changes in existing public health policy to include the use of laboratory methods such as microscopy and the introduction of malaria rapid diagnostic tests in order to reduce the incidence of malaria misdiagnosis in Uganda. Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43709&type=Document 5. Working without a blindfold: the critical role of diagnostics in malaria control Increases in the cases of malaria continue to pose a challenge for public health specialists. Despite advances in laboratory methods, pharmaceutical interventions and preventative measures, combating the increases in the cases of malaria still largely depends on the diagnosis and management of the disease. This paper highlights how efforts to control malaria are influenced by the use of inappropriate methods for the diagnosis and treatment of malaria. The authors argue that while there have been changes in the management of malaria, these gains will be lost if suitable diagnostic methods are not utilised. Traditionally, malaria was diagnosed through presumptive methods - that is the presence of a fever. While the authors recognise that this has resulted in positive health outcomes for some, the absence of laboratory methods for the diagnosis of malaria has resulted in the over-diagnosis of the disease. Furthermore, improper diagnosis of malaria can result in: wasted resources due to the prescription of anti-malarial drugs for patients who do not need them, drug resistance due to the improper use of the medications, and changes in public opinion about the disease and persons who are found to be positive. The authors present the case for the use of rapid diagnostic tests in places where microscopy is unavailable as they recognise that the latter form of diagnosis is not only costly but difficult to utilise in remote settings. They also discuss methods to ensure the quality of the various diagnostic methods. The paper concludes by reiterating the need to utilise laboratory based methods of diagnosis rather than reliance on syndromic management, namely classifying all 'malaria-like' fevers as malaria, due to the increased likelihood for mis-diagnosis. Available online at: www.eldis.org/go/topics/resource-guides/health-systems&id=43708&type=Document See the complete list of latest additions at: www.eldis.org/healthsystems Conference: 6th European Congress on Tropical Medicine and International Health, ‘Equity, Human Rights and Access to Care’ The central focus of this conference, organised by the Federation of European Societies for Tropical Medicine and International Health (FESTMIH), will be on its main theme: Equity, Human Rights and Access to Care. This event aims to deal with the classical aspects of tropical medicine including basic science, diagnostic/therapeutics and disease control, and will include an emphasis on transferability of research results into actual practice. Discussions will also address the North-South gap in health research, in all main aspects: space devoted to global health in medical journals; role of researchers from the South in relevant publications; share of research which is actually devoted to priority areas; important gaps that remain to be filled in research in tropical medicine and international health; difficulties in financing health system research. More details available online at: www.eldis.org/go/topics/resource-guides/health/health-events-and-announcements&id=42854&type=Item Training: Rational Management of Medicines - a focus on HIV/AIDS, Tuberculosis and Malaria This two week course, run by the Swiss Tropical Institute, aims to enable health professionals to understand and apply the concepts and principles of essential medicines and rational medicine management with a focus on the diseases of poverty HIV/AIDS, malaria and tuberculosis. This is in order to recognise the need for a national and international medicine policy environment, to improve knowledge and skills and to gain practical field experience for rational medicine management within different health system contexts. The course is most suited to health professionals and managers with at least two years experience in international health and the pharmaceutical sector. It will be conducted in a rural area of Tanzania and will be complemented with field visits experience to address the know-do gap and the system approach to diseases of poverty. The course is unique in combining theoretical knowledge with the reality of a rural district and the questions and skills related to medicine access. More details available online at: www.eldis.org/go/topics/resource-guides/health/health-events-and-announcements&id=42976&type=Item See the complete list of announcements at: http://www.eldis.org/go/topics/resource-guides/health/health-events-and-announcements The Health Systems Reporter is produced by the IDS Health and Development Information team in collaboration with the DFID Health Resource Centre (HRC) and Eldis. The IDS Health and Development Information team promotes health and equity in developing countries through the provision of high quality, accessible information to policymakers and practitioners. IDS Health and Development Information currently has three flagship products:
The HRC provides access to technical assistance and information for the Department for International Development (DFID UK), and its partners, in support of pro-poor health policies as well as health systems, service delivery and public health topics and programmes. Eldis currently includes descriptions and links to over 4,500 organisations and over 22,000 full-text online documents covering development and environmental issues. It can be searched or browsed free over the Internet. You are welcome to re-use material from this bulletin on your own website, provided that it is accompanied by an acknowledgement to Eldis and a link to the Eldis website (either to our home page or to the home page of one of our Resource Guides). An alternative way to add Eldis content to your website is by adding one of our newsfeeds. If you are unable to access any of these materials online and would like to receive a copy of a document as an email attachment, please contact our editor at the email address given below. Eldis is funded by DFID, Sida, SDC and NORAD, and hosted by the Institute of Development Studies, Sussex, UK. If you like the Health Systems Reporter, you may also be interested in subscribing to the other Reporters produced by the IDS Health & Development Information Team:
To unsubscribe, send a blank email to lyris@... with the subject: "unsubscribe eldis-healthsystems". Please forward this email bulletin to colleagues and networks who may be interested. Contact details: IDS Health Development Information Team |
|
Yahoo! Groups TipsDid you know...Want your group to be featured on the Yahoo! Groups website? Add a group photo to Flickr. |
Having problems with message search?
Fill out this form to ensure your group is one of the first to be migrated to the new message search system.
|
Send Email