The effect of India's total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh: a cluster randomized controlled trial

Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth).

The policy implications of better structure and process on birth outcomes in Jamaica.

BACKGROUND: We investigated if better structural and process elements of prenatal care relate to higher birth weights in the Jamaican population. METHODS: We used data from two surveys: (1) a national sample of randomly selected households; and (2) a concurrent facility survey of the public health clinics in Jamaica. In the household survey, all women aged 14-50, who had a pregnancy lasting 7 months during the previous 5 years (n = 913) were interviewed. From the household survey, we gathered information on the maternal, clinical and socioeconomic risk factors and on the newborns birth weight (the outcome measure). The facility survey collected data from all public primary care clinics in the country (n = 366). This gave us information on the quality of care (structure and process measures) provided in the clinics. FINDINGS: Prenatal care in Jamaica, while generally available, provides care to many women who are at particular risk because of parity, age and poverty. Structural measures of the facilities show that clinics are in general disrepair, have only 70% of the basic equipment and are insufficiently stocked with supplies or medication. Many facilities had poor process of care, as measured by assessing the clinical examination and counseling. The average birth weight was 3232 g and 9.8% weighed < 2500 g. The relationships between birth weight and the quality of care were estimated using multiple regression. The biologic and socioeconomic risk factors related to birth weight in the expected direction. None of the structural quality measures were statistically significant. Among the process measures, women who had access to a more complete examination, had infants that weighed an average of 128 g more at birth. INTERPRETATION: Better quality of care, provided by a more thorough clinical evaluation, has a more powerful effect on birth weight in the population than upgraded facilities or equipment. In developed or developing countries, where resources are limited, policy should focus on education and training to improve birth outcomes.

Are clinical criteria just proxies for socioeconomic status? A study of low birth weight in Jamaica.

OBJECTIVE: To determine if the clinical risk factors for low birth weight are independent of socioeconomic risk factors in a population based sample from a developing country. DESIGN: Survey data from patient reported socioeconomic measures and their most recent pregnancy history. SETTING: A national sample of randomly selected households in Jamaica. SUBJECTS: All women aged 14-50 in the household who had a pregnancy lasting seven months in the past five years (n = 952). MAIN OUTCOME MEASURE: Birth weight. RESULTS: Clinical risk factors for low birth weight, such as parity age, are independent of socioeconomic determinants, such as consumption and where a mother lives. Women who are nulliparous, 35 or older, poor, or living in certain areas are more likely to have lower birth weight children than those that do not have these characteristics (t statistics > 2.0). The addition of socioeconomic factors to the multiple regression does not alter the estimates for the clinical risk factors for low birth weight. Thus, the effect of being nulliparous can be offset by being in the highest consumption quintile and, conversely, the risk of being older will be compounded if women are poor. CONCLUSIONS: Both clinical and socioeconomic risk factors should be used to target women at risk. In terms of the quality of care, this study links clinical and socioeconomic risk factors to poor outcomes. Further studies are needed, however, to link the quality of care at various locations to these outcomes.

The impact of maternal health improvement on perinatal survival: cost-effective alternatives.

Each year, an estimated half million women die from complications related to child birth either during pregnancy, delivery or within 42 days afterwards. When pregnant women have complications, their infants are at greater risk of becoming ill, permanently disabled or dying. For every maternal death, there are at least 20 infant deaths: stillbirths, neonatal or postneonatal deaths. Altogether, an estimated 7 million infants each year die perinatally (stillborn or deaths within the first week of life). Low cost, feasible, and effective intervention strategies include: a) improved family planning and abortion services; b) obstetric care at delivery; and, c) prenatal services. Two hypothetical populations of one million (a low mortality and a high mortality country) are used to illustrate maternal and perinatal program strategies and priorities. In countries with high fertility, major reductions in maternal and infant deaths result both from reductions in the number of pregnancies through family planning and from improved obstetric care. Where fertility is already low, reductions result almost entirely from improved obstetric and prenatal care. The investments required are relatively low, while the potential gains are great. The cost to avert each death in a high mortality population is estimated between $800 and $1,500 or as low as $0.50 per capita per year. The priorities for programs targeting maternal and perinatal health depend on demographic, ecologic and economic factors, and should include the promotion of good health, not merely the avoidance of death. More operational research is required on various aspects of maternal and perinatal health; in particular, on the cost-effectiveness of different service components.

How economic development and family planning programs combined to reduce Indonesian fertility.

This paper examines the contributions of family planning programs, economic development, and women's status to Indonesian fertility decline from 1982 to 1987. Methodologically we unify seemingly conflicting demographic and economic frameworks into a single "structural" proximate-cause model as well as controlling statistically for the targeted (nonrandom) placement of family planning program inputs. The results are consistent with both frameworks: 75% of the fertility decline resulted from increased contraceptive use, but was induced primarily through economic development and improved education and economic opportunities for females. Even so, the dramatic impact of the changes in demand-side factors (education and economic development) on contraceptive use was possible only because there already existed a highly responsive contraceptive supply delivery system.

The resource utilization group system: its effect on nursing home case mix and costs.

Using data from 1985 and 1986, we examine how New York state's prospective payment system affected nursing homes. The system, called Resource Utilization Group (RUG-II), aimed to limit nursing home cost growth and improve access to nursing homes by "heavy-care" patients. As in Medicare's prospective hospital reimbursement system, payments to nursing homes were based on a "price," rather than facility-specific rates. With respect to cost growth, we observed considerable diversity among homes. Specifically, those nursing homes most financially constrained by the RUG-II methodology exhibited the slowest rates of cost growth; we observed higher cost growth among the homes least constrained. This higher rate of cost growth raises a question about the desirability of using a pricing methodology to determine nursing home payment rates. In addition to moderating cost growth, we also observed a significant change in the mix of patients admitted to nursing homes. During the first year of the RUG-II program, nursing homes admitted more heavy-care patients and reduced days of care to lighter-care patients. Thus, through 1986, the RUG-II program appeared to satisfy at least one of its major policy objectives.

A comparison of length of stay and costs for health maintenance organization and fee-for-service patients.

Enrollees of health maintenance organizations (HMOs) are less frequently hospitalized than are patients cared for by fee-for-service physicians. To determine if care provided to HMO and fee-for-service patient is different once they are hospitalized, we compared length of stay, total costs, and severity of illness for 617 HMO and fee-for-service patients hospitalized during the period 1983 through 1985 at a major teaching hospital. Severity was gauged in the following two ways: the Severity of Illness Index developed by Horn, and ratings by two physicians who were given all records from the first day of each patient's hospitalization. Length of stay was shorter and total costs were less for HMO patients in 7 of 11 diagnosis related groups. Using regression analysis to adjust for age, sex, emergency ward admission, diagnosis related group, and severity, we found that overall length of stay was 14% shorter for HMO patients than for fee-for-service patients (6.2 vs 5.3 days, P less than .01), whereas total costs were only 4% less ($4251 vs $4090, P greater than .2). These findings indicate that while patterns of utilization may vary by diagnosis related groups, HMO patients had shorter lengths of stay but comparable overall costs. Whether shorter lengths of stay represent greater efficiency, substitution of outpatient for inpatient care, or diminution in the quality of care is not clear.

The effect of Medicaid policy on mental health and poverty.

This paper examines the interrelationships between mental distress, poverty, and Medicaid eligibility policy. This is accomplished by estimating an econometric model of mental health and income. We use data from a community survey to estimate the model. Simulations of the impacts of changes in Medicaid eligibility policy are performed using the model estimates. A central finding is that while there are gains in both mental health status and earnings from changes in Medicaid, the effects on poverty are small because of the design of transfer programs. Suggestions for further research are offered.