The heads of the Global Fund and the GAVI Alliance have recently promoted the idea of an international tiered pricing framework for medicines, despite objections from civil society groups who fear that this would reduce the leeway for compulsory licenses and generic competition. This paper explores the extent to which an international tiered pricing framework and the present leeway for compulsory licensing can be reconciled, using the perspective of the right to health as defined in international human rights law.
We explore the practical feasibility of an international tiered pricing and compulsory licensing framework governed by the World Health Organization. We use two simple benchmarks to compare the relative affordability of medicines for governments – average income and burden of disease – to illustrate how voluntary tiered pricing practice fails to make medicines affordable enough for low and middle income countries (if compared with the financial burden of the same medicines for high income countries), and when and where international compulsory licenses should be issued in order to allow governments to comply with their obligations to realize the right to health.
An international tiered pricing and compulsory licensing framework based on average income and burden of disease could ease the tension between governments’ human rights obligation to provide medicines and governments’ trade obligation to comply with the Agreement on Trade-Related Aspects of Intellectual Property Rights.
Right to health; Tiered pricing; TRIPS; Medicines; Patent; Compulsory licensing
Donor engagement in transitional settings, complex emergencies and fragile states is increasing. Neither short-term humanitarian aid nor traditional development financing are well adapted for such environments. Multi-donor trust funds, in their current form, can be unwieldy and subject to long delays in initiation and work best when national governments are already strong. We reviewed the aid modalities used in Zimbabwe through the period of crisis, 2008–2012 and their results and implications. Literature review and case experience was utilised.
By focusing on working with line ministries in non-contested sectors to determine local priorities rather than following global prescriptions, pooling funds to achieve scale rather than delivering through fragmented projects, and building on national systems and capacities rather than setting up parallel mechanisms, the Transition Fund Model employed in Zimbabwe by UNICEF and partners in partnership with the Inclusive Government was able to achieve important results in health, education, social support and water services in a challenging setting. In addition, forums for collaboration were developed that provided a platform for further action. The initial emphasis on service delivery diffused much of the political delicateness that impeded progress in other sectors. The Zimbabwean experience may provide a model of innovative financing for countries facing similar circumstances.
Such models may represent a new practical application of the Paris Principles, consistent with the major tenets of the 2011 New Deal for Engagement in Fragile States agreed in Busan. As we approach the Millennium Development Goal deadline, an over-arching, mutli-sectoral and independent evaluation of this approach is recommended in order to validate findings and assess broader replicability of this approach.
Public health recommendations are usually based on a mixture of empirical evidence and normative arguments: to argue that authorities ought to implement an intervention that has proven effective in improving people’s health requires a normative position confirming that the authorities are responsible for improving people’s health. While public health (at the national level) is based on a widely accepted normative starting point – namely, that it is the responsibility of the state to improve people’s health – there is no widely accepted normative starting point for international health or global health. As global health recommendations may vary depending on the normative starting point one uses, global health research requires a better dialogue between researchers who are trained in empirical disciplines and researchers who are trained in normative disciplines.
Global health researchers with a background in empirical disciplines seem reluctant to clarify the normative starting point they use, perhaps because normative statements cannot be derived directly from empirical evidence, or because there is a wide gap between present policies and the normative starting point they personally support. Global health researchers with a background in normative disciplines usually do not present their work in ways that help their colleagues with a background in empirical disciplines to distinguish between what is merely personal opinion and professional opinion based on rigorous normative research.
If global health researchers with a background in empirical disciplines clarified their normative starting point, their recommendations would become more useful for their colleagues with a background in normative disciplines. If global health researchers who focus on normative issues used adapted qualitative research guidelines to present their results, their findings would be more useful for their colleagues with a background in empirical disciplines.
Although a single common paradigm for all scientific disciplines that contribute to global health research may not be possible or desirable, global health researchers with a background in empirical disciplines and global health researchers with a background in normative disciplines could present their ‘truths’ in ways that would improve dialogue. This paper calls for an exchange of views between global health researchers and editors of medical journals.
Global health; International health; Human rights; Ethics; Empirical; Normative; Is-ought problem; Interdisciplinary research
Tuberculosis is a highly contagious disease, and there has been a rise in recent years of drug-resistant cases no longer responding to standard treatment.
In order to address this threat and contain possible transmission of drug-resistant cases, some countries have taken strong action, including the compulsory detention of non-adherent drug-resistant patients. These measures have been strongly criticized by human rights advocates, and they raise the question of how to legally protect both citizens and the community.
Following discussions with National Tuberculosis Programs in Africa (the continent with the highest incidence rates of tuberculosis worldwide), we show that of all the countries surveyed, all but one (Swaziland) had either no specific policy addressing tuberculosis, or only general policies regarding public health applicable to tuberculosis. Six countries also reported having policies that address non-adherence to treatment with containment (isolation in health facilities or incarceration), but laws are not adequately enforced. If the international community wants to effectively respond to the threat of tuberculosis transmission, there is a need to go beyond national tuberculosis policies and to implement an international framework for tuberculosis control, inspired by the Framework Convention on Tobacco Control, a key model for future public health treaties that address global burdens of disease. The framework, for which we clarify the conditions and procedures in this piece, would define the rights and responsibilities of the different stakeholders involved: patients, doctors, pharmaceutical firms and public authorities. To facilitate the governance of the national obligations under the Convention, a coordinating body should be set up, under the leadership of the World Health Organization and the Stop TB Partnership.
Successfully implementing policies for tuberculosis that simultaneously address patients’ rights and communities’ wellbeing will have positive implications for those affected by the disease and serve as a basis for other global health conventions to truly ensure the global right to health.
Tuberculosis; Drug-resistant tuberculosis; Framework convention; Human rights
Men’s participation is crucial to the success of family planning programs and women’s empowerment and associated with better outcomes in reproductive health such as contraceptive acceptance and continuation, and safer sexual behaviors. Limited choice and access to methods, attitudes of men towards family planning, perceived fear of side-effects, poor quality of available services, cultural or religious oppositions and gender-based barriers are some of the reasons for low utilization of family planning. Hence, this study assessed the level of male involvement in family planning services utilization and its associated factors in Debremarkos town, Northwest Ethiopia.
A community-based cross-sectional study was conducted from October to November, 2013. Multi-stage sampling technique was used to select 524 eligible samples. Data were collected by using semi-structured questionnaires. Epi Info and SPSS were used to enter and analyze the data; univariate, bivariate and logistic regression analyses were performed to display the outputs.
Only 44 (8.4%) respondents were using or directly participating in the use of family planning services mainly male condoms. The reasons mentioned for the low participation were the desire to have more children, wife or partner refusal, fear of side effects, religious prohibition, lack of awareness about contraceptives and the thinking that it is the only issue for women. Opinion about family planning services, men approval and current use of family planning methods were associated with male involvement in the services utilization.
In this study, the level of male involvement was low. Lack of information, inaccessibility to the services and the desire to have more children were found to be the reasons for low male involvement in family planning services utilization. Governmental and nongovernmental organizations, donors and relevant stakeholders should ensure availability, accessibility and sustained advocacy for use of family planning services. The family planning programs should incorporate the responsibility and role of males in the uptake of family planning services.
Male involvement; Family planning services; Ethiopia
The face of international aid for health and development is changing. Private donors such as foundations and corporations are playing an increasingly important role, working in international development as direct operators or in partnerships with governments. This study compares maternal health programs of new development actors to traditional governmental donors. It aims to investigate what maternal health programs large governmental donors, foundations and corporate donors are conducting, and how and why they differ.
A total of 263 projects were identified and analyzed. We focus on nine categories of maternal health programs: family planning services, focus on specific diseases, focus on capacity building, use of information and communication technology (ICT), support of research initiatives, cooperation with local non-state or state partners and cooperation with non-local non-state or state partners. Data analysis was carried out using Generalized Linear Mixed-Effects Models (GLMER).
Maternal health policies of public and private donors differ with regard to strategic approaches, as can be seen in their diverging positions regarding disease focus, family planning services, capacity building, and partner choice. Bilateral donors can be characterized as focusing on family planning services, specific diseases and capacity-building while disregarding research and ICT. Bilateral donors cooperate with local public authorities and with governments and NGOs from other developed countries. In contrast, corporations focus their donor activities on specific diseases, capacity-building and ICT while disregarding family planning services and research. Corporations cooperate with local and in particular with non-local non-state actors. Foundations can be characterized as focusing on family planning services and research, while disregarding specific diseases, capacity-building and ICT. Foundations cooperate less than other donors; but when they do, they cooperate in particular with non-state actors, local as well as non-local.
These findings should help developing coordination mechanisms that embrace the differences and similarities of the different types of donors. As donor groups specialize in different contexts, NGOs and governments working on development and health aid may target donors groups that have specialized in certain issues.
Maternal health; Donors; Development projects; Corporations; Foundations
Male involvement (MI) in Prevention of mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) services remains low despite the progress registered in the implementation of the PMTCT program. Male involvement in PMTCT is a fairly new concept in Malawi that has not been fully implemented within PMTCT service provision despite its inclusion in the PMTCT guidelines. One of the reasons for the limited MI is the lack of knowledge on both its relevance and the role of men in the program. Currently, men have been encouraged to participate in PMTCT services without prior research on their understanding of the relevance and their role in PMTCT. This information is vital to the development of programs that will require MI in PMTCT. The objective of this study was to explore the views of men, pregnant women and health care providers on the importance and roles of MI in PMTCT services in Blantyre Malawi.
An exploratory descriptive qualitative study was conducted from December 2012 to January 2013 at South Lunzu Health Centre (SLHC) and its catchment area in Blantyre, Malawi. We conducted 6 key informant interviews (KIIs) with health care workers and 4 focus group discussions (FGDs) with 18 men and 17 pregnant women. Interviews and discussions were digitally recorded and simultaneously transcribed and translated into English. Data were analyzed using framework analysis approach.
The major themes that emerged on the relevance of MI in PMTCT were a) uptake of interventions along the PMTCT cascade b) support mechanism and c) education strategy. Lack of MI in PMTCT was reported to result into non-disclosure of HIV test results and non-compliance with PMTCT interventions.
Male involvement is paramount for the uptake of interventions at the different cascades of PMTCT. The absence of male involvement may compromise compliance with PMTCT interventions.
PMTCT; Male involvement; Relevance
This study focused on the 47 Member States of the World Health Organization (WHO) African Region. The specific objectives were to prepare a synthesis on the situation of health systems¿ components, to analyse the correlation between the interventions related to the health Millennium Development Goals (MDGs) and some health systems¿ components and to provide overview of four major thrusts for progress towards universal health coverage (UHC).
The WHO health systems framework and the health-related MDGs were the frame of reference. The data for selected indicators were obtained from the WHO World Health Statistics 2014 and the Global Health Observatory.
African Region¿s average densities of physicians, nursing and midwifery personnel, dentistry personnel, pharmaceutical personnel, and psychiatrists of 2.6, 12, 0.5, 0.9 and 0.05 per 10 000 population were about five-fold, two-fold, five-fold, five-fold and six-fold lower than global averages.
Fifty-six percent of the reporting countries had fewer than 11 health posts per 100 000 population, 88% had fewer than 11 health centres per 100 000 population, 82% had fewer than one district hospital per 100 000 population, 74% had fewer than 0.2 provincial hospitals per 100 000 population, and 79% had fewer than 0.2 tertiary hospitals per 100 000 population.
Some 83% of the countries had less than one MRI per one million people and 95% had fewer than one radiotherapy unit per million population. Forty-six percent of the countries had not adopted the recommendation of the International Taskforce on Innovative Financing to spend at least US$ 44 per person per year on health. Some of these gaps in health system components were found to be correlated to coverage gaps in interventions for maternal health (MDG 5), child health (MDG 4) and HIV/AIDS, TB and malaria (MDG 6).
Substantial gaps exist in health systems and access to MDG-related health interventions. It is imperative that countries adopt the 2014 Luanda Commitment on UHC in Africa as their long-term vision and back it with sound policies and plans with clearly engrained road maps for strengthening national health systems and addressing the social determinants of health.
Health systems; Health workforce; Health facilities; Health technologies; Health financing; Information; Leadership and governance; Health interventions; Universal health coverage; African region
There is a growing understanding of the role social determinants such as poverty, gender discrimination, racial prejudice, and economic inequality play on health and illness. While these determinants and effects may be challenging to identify in parts of high-income countries, they are patently obvious in many other areas of the world. How we react to these determinants and effects depends on what historical, cultural, ideological, and psychological characteristics we bring to our encounters with inequity, as well as how our feelings and thoughts inform our values and actions.
To address these issues, we share a series of questions we have asked ourselves¿United States¿ citizens with experience living and working in Central America¿in relation to our encounters with inequity. We offer a conceptual framework for contemplating responses in hopes of promoting among educators and practitioners in medicine and public health an engaged awareness of how our every day work either perpetuates or breaks down barriers of social difference. We review key moments in our own experiences as global health practitioners to provide context for these questions.
Introspective reflection can help professionals in global medicine and public health recognize the dynamic roles that they play in the world. Such reflection can bring us closer to appreciating the forces that have worked both for and in opposition to global health, human rights, and well-being. It can help us recognize how place, time, environment, and context form the social determination of health. It is from this holistic perspective of social relations that we can work to effect fair, equitable, and protective environments as they relate to global medicine and public health.
Epidemiologic factors; Health knowledge; Attitudes; Practice; Internationality; Public health; Role; Professional; Social medicine
Campaigns have been conducted in a number of low HIV prevalence African settings, as a strategy to expand HIV testing, and it is important to assess the extent to which individual rights and quality of care are protected during campaigns. In this article we investigate provider and client perceptions of ethical issues, including whether they think that accessibility of counseling and testing sites during campaigns may hinder confidentiality.
To examine how campaigns have functioned in Burkina Faso, we undertook a qualitative study based on individual interviews and focus group discussions with 52 people (providers and clients tested during or outside campaigns and individuals never tested). Thematic analysis was performed on discourse about perceptions and experiences of HIV-testing campaigns, quality of care and individual rights.
Respondents value testing accessibility and attractiveness during campaigns; clients emphasize convenience, ripple effect, the sense of not being alone, and the anonymity resulting from high attendance. Confronted with numerous clients, providers develop context-specific strategies to ensure consent, counseling, confidentiality and retention in the testing process, and they adapt to workplace arrangements, local resources and social norms. Clients appreciate the quality of care during campaigns. However, new ethical issues arise about confidentiality and accessibility. Confidentiality of HIV-status may be jeopardized due to local social norms that encourage people to share their results with others, when HIV-positive people may not wish to do so. Providers’ ethical concerns are consistent with WHO norms known as the ‘5 Cs,’ though articulated differently. Clients and providers value the accessibility of testing for all during campaigns, and consider it an ethical matter. The study yields insights on the way global norms are adapted or negotiated locally.
Future global recommendations for HIV testing and counseling campaigns should consider accessibility and propose ways for testing services to respond to new ethical issues related to high demand.
HIV; Testing campaign; Ethics; Burkina Faso; Individual rights; Global norms; Stigma; Africa
In sub-Saharan Africa the availability of intensive care unit (ICU) services is limited by a variety of factors, including lack of financial resources, lack of available technology and well-trained staff. Tanzania has four main referral hospitals, located in zones so as to serve as tertiary level referral centers. All the referral hospitals have some ICU services, operating at varying levels of equipment and qualified staff. We analyzed and describe the disease patterns and clinical outcomes of patients admitted in ICUs of the tertiary referral hospitals of Tanzania.
This was a retrospective analysis of ICU patient records, for three years (2009 to 2011) from all tertiary referral hospitals of Tanzania, namely Muhimbili National Hospital (MNH), Kilimanjaro Christian Medical Centre (KCMC), Mbeya Referral Hospital (MRH) and Bugando Medical Centre (BMC).
MNH is the largest of the four referral hospitals with 1300 beds, and MRH is the smallest with 480 beds. The ratio of hospital beds to ICU beds is 217:1 at MNH, 54:1 at BMC, 39:1 at KCMC, and 80:1 at MRH. KCMC had no infusion pumps. None of the ICUs had a point-of-care (POC) arterial blood gas (ABG) analyzer. None of the ICUs had an Intensive Care specialist or a nutritionist. A masters-trained critical care nurse was available only at MNH. From 2009–2011, the total number of patients admitted to the four ICUs was 5627, male to female ratio 1.4:1, median age of 34 years. Overall, Trauma (22.2%) was the main disease category followed by infectious disease (19.7%). Intracranial injury (12.5%) was the leading diagnosis in all age groups, while pneumonia (11.7%) was the leading diagnosis in pediatric patients (<18 years). Patients with tetanus (2.4%) had the longest median length ICU stay: 8 (5,13) days. The overall in-ICU mortality rate was 41.4%.
The ICUs in tertiary referral hospitals of Tanzania are severely limited in infrastructure, personnel, and resources, making it difficult or impossible to provide optimum care to critically ill patients and likely contributing to the dauntingly high mortality rates.
The ‘Cash Transfer to Orphans and Vulnerable Children’ (CT-OVC) in Kenya is a government-supported program intended to provide regular and predictable cash transfers (CT) to poor households taking care of OVC. CT programs can be an effective means of alleviating poverty and facilitating the attainment of an adequate standard of living for people’s health and well-being and other international human rights. The objective of this analysis was to compare the household socioeconomic status, school enrolment, nutritional status, and future outlook of orphaned and separated children receiving the CT compared to those not receiving a CT.
This project analyzes baseline data from a cohort of orphaned and separated children aged <19 years and non-orphaned children living in 300 randomly selected households (HH) in 8 Locations of Uasin Gishu County, Kenya. Baseline data were analyzed using multivariable logistic and Poisson regression comparing children in CT-HH vs. non-CT HH. Odds ratios are adjusted (AOR) with 95% confidence intervals (CI) for guardian age and sex, child age and sex, and intra-HH correlation.
Included in this analysis were data from 1481 children and adolescents in 300 HH (503 participants in CT, 978 in non-CT households). Overall there were 922 (62.3%) single orphans, 324 (21.9%) double orphans, and 210 (14.2%) participants had both parents alive and were living with them. Participants in CT-HH were less likely to have ≥2 pairs of clothes compared to non-CT HH (AOR: 0.32, 95% CI: 0.16-0.63). Those in CT HH were less likely to have missed any days of school in the preceding month (AOR: 0.62, 95% CI: 0.42-0.94) and those aged <1-18 years in CT-HH were less likely to have height stunting for their age (AOR: 0.65, 95% CI: 0.47-0.89). Participants aged at least 10 years in CT-HH were more likely to have a positive future outlook (AOR: 1.72, 95% CI: 1.12-2.65).
Children and adolescents in households receiving the CT-OVC appear to have better nutritional status, school attendance, and optimism about the future, compared to those in households not receiving the CT, in spite of some evidence of continued material deprivation. Consideration should be given to expanding the program further.
Orphans; Africa; Cash transfer; Nutrition; Food security; Mental health
In spite of global decline in under-five mortality, the goal of achieving MDG 4 still remains largely unattained in low and middle income countries as the year 2015 closes-in. To accelerate the pace of mortality decline, proven interventions with high impact need to be implemented to help achieve the goal of drastically reducing childhood mortality. This paper explores the association between socio-economic and demographic factors and under-five mortality in an impoverished region in rural northern Ghana.
We used survey data on 3975 women aged 15–49 who have ever given birth. First, chi-square test was used to test the association of social, economic and demographic characteristics of mothers with the experience of under-five death. Subsequently, we ran a logistic regression model to estimate the relative association of factors that influence childhood mortality after excluding variables that were not significant at the bivariate level.
Factors that significantly predict under-five mortality included mothers’ educational level, presence of co-wives, age and marital status. Mothers who have achieved primary or junior high school education were 45% less likely to experience under-five death than mothers with no formal education at all (OR = 0.55, p < 0.001). Monogamous women were 22% less likely to experience under-five deaths than mothers in polygamous marriages (OR = 0.78, p = 0.01). Similarly, mothers who were between the ages of 35 and 49 were about eleven times more likely to experience under-five deaths than those below the age of 20 years (OR = 11.44, p < 0.001). Also, women who were married had a 27% less likelihood (OR = 0.73, p = 0.01) of experiencing an under-five death than those who were single, divorced or widowed.
Taken independently, maternal education, age, marital status and presence of co-wives are associated with childhood mortality. The relationship of these indicators with women’s autonomy, health seeking behavior, and other factors that affect child survival merit further investigation so that interventions could be designed to foster reductions in child mortality by considering the needs and welfare of women including the need for female education, autonomy and socioeconomic well-being.
Under-five mortality; Socio-economic; Demographic; Determinants; Rural; Ghana
Rape of women and children is recognized as a health and human rights issue in Tanzania and internationally. Exploration of the prevailing perceptions in rural areas is needed in order to expand the understanding of sexual violence in the diversity of Tanzania’s contexts. The aim of this study therefore was to explore and understand perceptions of rape of women and children at the community level in a rural district in Tanzania with the added objective of exploring those perceptions that may contribute to perpetuating and/or hindering the disclosure of rape incidences.
A qualitative design was employed using focus group discussions with male and female community members including religious leaders, professionals, and other community members. The discussions centered on causes of rape, survivors of rape, help-seeking and reporting, and gathered suggestions on measures for improvement. Six focus group discussions (four of single gender and two of mixed gender) were conducted. The focus group discussions were recorded, transcribed verbatim, and analyzed using manifest qualitative content analysis.
The participants perceived rape of women and children to be a frequent and hidden phenomenon. A number of factors were singled out as contributing to rape, such as erosion of social norms, globalization, poverty, vulnerability of children, alcohol/drug abuse and poor parental care. Participants perceived the need for educating the community to raise their knowledge of sexual violence and its consequences, and their roles as preventive agents.
In this rural context, social norms reinforce sexual violence against women and children, and hinder them from seeking help from support services. Addressing the identified challenges may promote help-seeking behavior and improve care of survivors of sexual violence, while changes in social and cultural norms are needed for the prevention of sexual violence.
Child sexual abuse; Community perceptions; Focus group discussions; Rape; Rural; Sexual violence; Tanzania
Nepal is experiencing a significant ‘treatment gap’ in mental health care. People with mental disorders do not always receive appropriate treatment due to a range of structural and individual issues, including stigma and poverty. The PRIME (Programme for Improving Mental Health Care) programme has developed a mental health care plan to address this issue in Nepal and four other low and middle income countries. This study aims to inform the development of this comprehensive care plan by investigating the perceptions of stakeholders at different levels of the care system in the district of Chitwan in southern Nepal: health professionals, lay workers and community members. It focuses specifically on issues of demand and access to care, and aims to identify barriers and potential solutions for reaching people with priority mental disorders.
This qualitative study consisted of key informant interviews (33) and focus group discussions (83 participants in 9 groups) at community and health facility levels. Data were analysed using a framework analysis approach.
As well as pragmatic barriers at the health facility level, mental health stigma and certain cultural norms were found to reduce access and demand for services. Respondents perceived the lack of awareness about mental health problems to be a major problem underlying this, even among those with high levels of education or status. They proposed strategies to improve awareness, such as channelling education through trusted and respected community figures, and responding to the need for openness or privacy in educational programmes, depending on the issue at hand. Adapting to local perceptions of stigmatised treatments emerged as another key strategy to improve demand.
This study identifies barriers to accessing care in Nepal that reach beyond the health facility and into the social fabric of the community. Stakeholders in PRIME’s integrated care plan advocate strategic awareness raising initiatives to improve the reach of integrated services in this low-income setting.
Demand; Access; Mental health care; Stigma; Treatment gap; Nepal
The unnecessary and unsafe use of injections is common in developing countries like Nepal. Policymakers have an important role in promoting rational and safe injection use. Hence, the present study was carried out to explore the perception of health policymakers regarding safe injection practice in Nepal.
An exploratory qualitative study design was used in this study. Key policymakers from both the central and regional level were selected using purposive sampling. A semi-structured questionnaire advocated by the World Health Organization (WHO) was used after modifying the context. Interviews were conducted to clarify doubts and obtain additional information. The data was analyzed manually using deductive content analysis technique.
In total, eleven policymakers participated. All unanimously agreed that injection safety is a problem and seven participants reported that injections are overused. They shared the opinion that injections are administered by various providers, including formal and informal health providers, and also quacks. Almost half the respondents reported that the National Drug Policy discourages injection overuse, while others reported that the policy contains no provisions regarding injection overuse. Most policymakers stated that only single-use disposable injection equipment is used to provide injection, while others thought that sterilizable glass syringe is also used. More than half of the participants believed that the quality of injection equipment available in the Nepalese market is not regulated by any government institution. Almost two-third of the policymakers stated that syringes and needles are not reused, while the rest thought syringes might be reused without sterilization in some parts of the country. Almost half of the respondents stated that illegal commercialization of used syringes exists in Nepal. Almost all respondents thought that health care institutions have a waste management plan, while more than half of them opined that such plans are limited to tertiary care hospitals located in the capital.
The result of this study revealed a divergence of views among policymakers, even among those in the same ministry. Though there has been some effort from the government to increase the safety of injection practices, greater efforts are required, especially with regard to standardization of policies and procedures related to injection practice.
Drug policy; Hazardous waste; Health policy; Injection; Needle stick injury; Nepal
In the context of a generalized epidemic and criminalization of homosexuality, men who have sex with men (MSM) in Malawi have a disproportionate burden of HIV compared to other adults. Past research has documented low uptake of HIV prevention and health services among MSM, self-reported fear of seeking health services, and concerns of disclosure of sexual orientation and discrimination in health settings. Qualitative research was conducted among MSM and health service providers in Blantyre, Malawi to understand underlying factors related to disclosure and health seeking behaviors and inform the development of a community-based comprehensive HIV prevention intervention.
Using peer recruitment, eight MSM participants representing a range of ages, orientations, and social and behavioral characteristics were enrolled for in-depth interviews. Five service providers were recruited from the district hospital, local health and STI clinics, and a HIV prevention service organization. We use the Health Belief Model as a framework to interpret the influential factors on 1) health seeking and uptake among MSM, and 2) influences on provision of services by healthcare providers for MSM.
Results highlight disclosure fears among MSM and, among providers, a lack of awareness and self-efficacy to provide care in the face of limited information and political support. Service providers reported concerns of adverse repercussions related to the provision of services to men in same sex sexual relationships. Some MSM demonstrated awareness of HIV risk but believed that within the wider MSM community, there was a general lack of HIV information for MSM, low awareness of appropriate prevention, and low perception of risks related to HIV infection.
Qualitative research highlights the need for appropriate information on both HIV risks and acceptable, effective HIV prevention options for MSM. Information and educational opportunities should be available to the wider MSM community and the health sector. Health sector interventions may serve to increase cultural and clinical competency to address health problems experienced by MSM. To ensure availability and use of services in light of the criminalization and stigmatization of same sex practices, there is need to increase the safety of uptake and provision of these services for MSM.
Health knowledge; Attitudes; Practice; HIV/AIDS; Men who have sex with men (MSM); Stigma; Malawi
An estimated 863 million people–a third of the world’s urban population–live in slums, yet there is little information on the disease burden in these settings, particularly regarding chronic preventable diseases.
From March to May 2012, we conducted a cluster randomized survey to estimate the prevalence of noncommunicable diseases (NCDs) and associated risk factors in a peri-urban shantytown north of Lima, Peru. Field workers administered a questionnaire that included items from the WHO World Health Survey and the WHO STEPS survey of chronic disease risk factors. We used logistic regression to assess the associations of NCDs and related risk factors with age and gender. We accounted for sampling weights and the clustered sampling design using statistical survey methods.
A total of 142 adults were surveyed and had a weighted mean age of 36 years (range 18–81). The most prevalent diseases were depression (12%) and chronic respiratory disease (8%), while lifetime prevalence of cancer, arthritis, myocardial infarction, and diabetes were all less than 5%. Fifteen percent of respondents were hypertensive and the majority (67%) was unaware of their condition. Being overweight or obese was common for both genders (53%), but abdominal obesity was more prevalent in women (54% vs. 10% in men, p < 0.001). Thirty-five percent of men binge drank and 34% reported current smoking; these behaviors were less common among women (4% binge drank, p < 0.001; 8% smoked, p = 0.002). Increasing age was associated with an increased risk of abdominal obesity (Odds Ratio (OR) = 1.04, 95% CI = 1.01, 1.07, p = 0.02), hypertension (OR = 1.06, 95% CI = 1.02, 1.10, p = 0.006), arthritis (OR = 1.07, 95% CI = 1.03, 1.11, p < 0.001) and cancer (OR = 1.13, 95% CI = 1.07, 1.20, p < 0.001) in adjusted models. The prevalences of other NCDs and related risk factors were similar when stratified by age or gender.
This study underlines the important burden of noncommunicable disease in informal settlements in Peru and suggests that prevention and treatment interventions could be optimized according to age and gender.
Peru; Slum; Shantytown; Noncommunicable disease
Despite a substantial decrease in child mortality in Ethiopia over the past decade, neonatal mortality remains unchanged (37/1000 live-births). This paper describes a qualitative study on beliefs and practices on immediate newborn and postnatal care in four rural communities of Ethiopia conducted to inform development of a package of community-based interventions targeting newborns.
The study team conducted eight key informant interviews (KII) with grandmothers, 27 in-depth interviews (IDI) with mothers; seven IDI with traditional birth attendants (TBA) and 15IDI with fathers, from four purposively selected communities located in Sidama Zone of Southern Nationalities, Nations, and Peoples (SNNP) Region and in East Shewa and West Arsi Zones of Oromia Region.
In the study communities deliveries occurred at home. After cutting the umbilical cord, the baby is put to the side of the mother, not uncommonly with no cloth covering. This is largely due to attendants focusing on delivery of the placenta which is reinforced by the belief that the placenta is the ‘house’ or ‘blanket’ of the baby and that any “harm” caused to the placenta will transfer to the newborn. Applying butter or ointment to the cord “to speed drying” is common practice. Initiation of breastfeeding is often delayed and women commonly report discarding colostrum before initiating breastfeeding. Sub-optimal breastfeeding practices continue, due to perceived inadequate maternal nutrition and breast milk often leading to the provision of herbal drinks. Poor thermal care is also demonstrated through lack of continued skin-to-skin contact, exposure of newborns to smoke, frequent bathing—often with cold water baths for low-birth weight or small babies; and, poor hygienic practices are reported, particularly hand washing prior to contact with the newborn.
Cultural beliefs and newborn care practices do not conform to recommended standards. Local perspectives related to newborn care practices should inform behaviour change messages. Such messages should target mothers, grandmothers, TBAs, other female family members and fathers.
Ethiopia; Newborn care; Qualitative methods; Cultural beliefs
Male involvement in contraceptive use is increasingly becoming a global reproductive health issue. Vasectomy is one of the two male modern contraceptive methods espoused by the National Family Planning Policy in Ghana. Despite these advocacies, there are reports of low patronage of this method in Ghana. This study adhering to RATS guidelines on qualitative research therefore explored the social and cultural factors that may be affecting the low vasectomy uptake in Southern Ghana.
The study was conducted in Sefwi Bibiani-Ahwiaso Bekwai (SBAB) District and Komenda-Edina-Eguafo-Abrem (KEEA) Municipal area in the Western and Central regions of Ghana respectively. Twelve Focus Group Discussions were held with both male and female community members. In-depth interviews were also carried out with Community Health Officers (CHOs), Community Health Volunteers (CHVs) and health managers at both the district and regional levels. The discussions and interviews were recorded, transcribed verbatim and analysed using Nvivo 10.
The study revealed that vasectomy was perceived as an act against God, which was punishable either by death or answerable on judgement day. Vasectomy was also perceived to be a form of castration, which can make men weak and incapable, thereby unable to satisfy their wives sexually, leading to marital conflicts. Women were more concerned about the negative effects of vasectomy on men. Cafalgin and panacin which are locally manufactured analgesics were perceived to have contraceptive abilities and therefore used by men as an alternative to modern contraceptive methods.
Stigma and the misconceptions in the community may be accounting for the low vasectomy uptake in Ghana despite several advocacy strategies. Women were highly influential in a man's decision on vasectomy. This calls for the need to increase health education to demystify the misconceptions about vasectomy. Vasectomy-related campaign messages should target both men and women.
Vasectomy; Pregnancy; Family Planning; Male involvement; Southern Ghana
Myanmar/Burma has received increased development and humanitarian assistance since the election in November 2010. Monitoring the impact of foreign assistance and economic development on health and human rights requires knowledge of pre-election conditions.
From October 2008-January 2009, community-based organizations conducted household surveys using three-stage cluster sampling in Shan, Kayin, Bago, Kayah, Mon and Tanintharyi areas of Myanmar. Data was collected from 5,592 heads of household on household demographics, reproductive health, diarrhea, births, deaths, malaria, and acute malnutrition of children 6–59 months and women aged 15–49 years. A human rights focused survey module evaluated human rights violations (HRVs) experienced by household members during the previous year.
Estimated infant and under-five rates were 77 (95% CI 56 to 98) and 139 (95% CI 107 to 171) deaths per 1,000 live births; and the crude mortality rate was 13 (95% CI 11 to 15) deaths per thousand persons. The leading respondent-reported cause of death was malaria, followed by acute respiratory infection and diarrhea, causing 21.2% (95% CI 16.5 to 25.8), 16.6% (95% CI 11.8 to 21.4), and 12.3% (95% CI 8.7 to 15.8), respectively. Over a third of households suffered at least one human rights violation in the preceding year (36.2%; 30.7 to 41.7). Household exposure to forced labor increased risk of death among infants (rate ratio (RR) = 2.2; 95% CI 1.1 to 4.4) and children under five (RR = 2.1; 95% CI 1.3 to 3.6). The proportion of children suffering from moderate to severe acute malnutrition was higher among households that were displaced (prevalence ratio (PR) = 3.3; 95% CI 1.9 to 5.6).
Prior to the 2010 election, populations of eastern Myanmar experienced high rates of disease and death and high rates of HRVs. These population-based data provide a baseline that can be used to monitor national and international efforts to improve the health and human rights situation in the region.
Burma; Myanmar; Human Rights; Health; Mortality; Malaria
Timor-Leste is a young developing country in Asia. Most of its infrastructure was destroyed after a long armed conflict for independence. Despite recent expansion of health facilities and investment in healthcare, maternal mortality remains high with most mothers still giving birth at home. This study investigated factors affecting the non-utilisation of health service for childbirth in the aftermath of the independence conflict.
The Timor-Leste Demographic and Health Survey 2009-2010 was the latest two-stage national survey, which used validated questionnaires to obtain information from 26 clusters derived from 13 districts of the country. Factors influencing non-utilisation of health facility for childbirth were investigated using univariate and multivariable logistic regression analyses, accounting for the cluster sampling and sample weight of the survey.
Of the total 5986 participants included in the study, 4472 (74.8%) did not deliver their last child at a health facility. Lack of education for the mother (adjusted odds ratio (OR): 2.04; 95% confidence interval (CI) 1.56 to 2.66) and her partner (OR: 1.45; 95% CI 1.14 to 1.84), low household wealth status (OR: 5.20; 95% CI 3.93 to 6.90), and rural residence (OR: 2.83; 95% CI 2.22 to 3.66), were associated with increased likelihood of non-utilisation of health facility for childbirth. Working mothers (OR: 1.55; 95% CI 1.32 to 1.81), who had high parity (OR: 1.78; 95% CI 1.36 to 2.32) and did not attend antenatal care service (OR: 4.68; 95% CI 2.65 to 8.28) were also vulnerable for not delivering at a health facility. Conversely, the prevalence of non-utilisation of health facility for childbirth reduced with increasing number of service components received during antenatal care visits (OR: 0.72; 95% CI 0.64 to 0.80).
Only a quarter of Timorese women delivered at a health facility. In order to reduce maternal mortality, future interventions should target disadvantaged mothers from poor families, those residing in rural areas, have higher parity but no education, and who seldom attend antenatal care service, by improving their utilisation of health facility for childbirth.
Facility-based childbirth; Home delivery; Maternal health services; Timor-Leste
Female Genital Cutting (FGC) anchored in a complex socio-cultural context becomes significant at the interface of access of health and social services in host countries. The practice of FGC at times, understood as a form of gender-based violence, may result in unjustifiable consequences among girls and women; yet, these practices are culturally engrained traditions with complex meanings calling for ethically and culturally sensitive health and social service provision. Intents and meanings of FGC practice need to be well understood before before any policies that criminalize and condemn are derived and implemented.
FGC is addressed as a global public health issue with complex legal and ethical dimensions which impacts ability to access services, far beyond gender sensitivity. The ethics of terminology are addressed, building on the sustained controversial debate in regards to the delicate issue of conceptualization. An overview of international policies is provided, identifying the current trend of condemnation of FGC practices. Socio-cultural and ethical challenges are discussed in light of selected findings from a community-based research project. The illustrative examples provided focus on Western countries, with a specific emphasis on Canada.
The examples provided converge with the literature confirming the utmost necessity to engage with the FGC practicing communities allowing for ethically sensitive strategies, reduction of harm in relation to systems of care, and prevention of the risk of systematic gendered stigmatization. A culturally competent, gender and ethically sensitive approach is argued for to ensure the provision of quality ethical care for migrant families in host countries. We argue that socio-cultural determinants such as ethnicity, migration, sex and gender need to be accounted for as integral to the social construction of FGC.
Working partnerships between the public health sector and community based organisations with a true involvement of women and men from practicing communities will allow for more sensitive and congruent clinical guidelines. In order to honour the fundamental principles and values of medical ethics, such as compassion, beneficence, non-malfeasance, respect, and justice and accountability, socio-cultural interactions at the interface of health and migration will continue to require proper attention. It entails a commitment to recognise the intrinsic value and dignity of girls’ and women’s context.
Female genital cutting; Female genital mutilation; Traditional practices; Migration; Public health; Ethics; Harm reduction; Community engagement; Cultural sensitivity
Infections account for up to a half of neonatal deaths in low income countries. The umbilicus is a common source of infection in such settings. This qualitative study investigates practices and perspectives related to umbilical cord care in Ethiopia.
In-depth interviews (IDI) were conducted in a district in each of the four most populous regions in the country: Oromia, Amhara, Tigray and Southern Nations, Nationalities and Peoples Region (SNNPR). In each district, one community was purposively selected; and in each study community, IDIs were conducted with 6 mothers, 4 grandmothers, 2 Traditional Birth Attendants and 2 Health Extension Workers (HEWs). The two main questions in the interview guide related to cord care were: How was the umbilical cord cut and tied? Was anything applied to the cord stump immediately after cutting/in the first 7 days? Why was it applied/not applied?
The study elucidates local cord care practices and the rational for these practices. Concepts underlying cord tying practices were how to stem blood flow and facilitate delivery of the placenta. Substances were applied on the cord to moisturize it, facilitate its separation and promote healing. Locally recognized cord problems were delayed healing, bleeding or swelling. Few respondents reported familiarity with redness of the cord - a sign of infection. Grandmothers, TBAs and HEWs were influential regarding cord care.
This study highlights local rationale for cord practices, concerns about cord related problems and recognition of signs of infection. Behavioral change messages aimed at improving cord care including cleansing with CHX should address these local perspectives. It is suggested that HEWs and health facility staff target mothers, grandmothers, TBAs and other community women with messages and counseling.
Umbilical cord care; Newborns; Infection; Ethiopia