The Inverse Equity Hypothesis: Analyses of Institutional Deliveries in 286 National Surveys.

OBJECTIVES: To test the inverse equity hypothesis, which postulates that new health interventions are initially adopted by the wealthy and thus increase inequalities-as population coverage increases, only the poorest will lag behind all other groups. METHODS: We analyzed the proportion of births occurring in a health facility by wealth quintile in 286 surveys from 89 low- and middle-income countries (1993-2015) and developed an inequality pattern index. Positive values indicate that inequality is driven by early adoption by the wealthy (top inequality), whereas negative values signal bottom inequality. RESULTS: Absolute inequalities were widest when national coverage was around 50%. At low national coverage levels, top inequality was evident with coverage in the wealthiest quintile taking off rapidly; at 60% or higher national coverage, bottom inequality became the predominant pattern, with the poorest quintile lagging behind. CONCLUSIONS: Policies need to be tailored to inequality patterns. When top inequalities are present, barriers that limit uptake by most of the population must be identified and addressed. When bottom inequalities exist, interventions must be targeted at specific subgroups that are left behind.

The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004.

BACKGROUND: Middle-income countries will need to drastically reduce neonatal deaths to achieve the Millennium Development Goal for child survival. The evolution of antenatal and perinatal care indicators in the Brazilian city of Pelotas from 1982 to 2004 provides a useful case study of potential challenges. METHODS: We prospectively studied three birth cohorts representing all urban births in 1982, 1993, and from January to July, 2004. The same methods were used in all three studies. FINDINGS: Despite improvements in maternal characteristics, prevalence of preterm births increased from 6.3% (294 of 4665) in 1982 to 16.2% (342 of 2112) in 2004, corresponding to a 47 g reduction in mean birthweight. Average number of antenatal visits in 2004 was 8.3 per woman, but quality of care was still inadequate--97% of women had an ultrasound scan, but only 1830 (77%) had a vaginal examination and 559 of 1748 non-immunised women did not receive tetanus toxoid. Rate of caesarean sections increased greatly, from 28% (1632 of 5914) in 1982 to 43% (1039 of 2403) in 2004, reaching 374 of 456 (82%) of all private deliveries in 2004. The increased rate of preterm births seemed to result largely from caesarean sections or inductions. Newborn care improved, and gestational-age-specific mortality rates had fallen by about 50% since 1982. As a result, neonatal mortality rates had been stable since 1990, despite the increase in preterm deliveries. INTERPRETATION: Excessive medicalisation--including labour induction, caesarean sections, and inaccurate ultrasound scans--led by an unregulated private sector with spill-over effects to the public sector, might offset the gains resulting from improved maternal health and newborn survival. These challenges will have to be faced by middle-income countries striving to achieve the child survival Millennium Development Goal.

Achieving universal coverage with health interventions.

Cost-effective public health interventions are not reaching developing country populations who need them. Programmes to deliver these interventions are too often patchy, low quality, inequitable, and short-lived. We review the challenges of going to scale, building on known, effective interventions to achieve universal coverage. One challenge is to choose interventions consistent with the epidemiological profile of the population. A second is to plan for context-specific delivery mechanisms effective in going to scale, and to avoid uniform approaches. A third is to develop innovative delivery mechanisms that move incrementally along the vertical-to-horizontal axis as health systems gain capacity in service delivery. The availability of sufficient funds is essential, but constraints to reaching universal coverage go well beyond financial issues. Accurate estimates of resource requirements need a full understanding of the factors that limit intervention delivery. Sound decisions need to be made about the choice of delivery mechanisms, the sequence of action, and the pace at which services can be expanded. Strong health systems are required, and the time frames and funding cycles of national and international agencies are often unrealistically short.

The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions.

The Multi-Country Evaluation of the Integrated Management of Childhood Illness (IMCI) includes studies of the effectiveness, cost, and impact of the IMCI strategy in Bangladesh, Brazil, Peru, Tanzania, and Uganda. Seven questions were addressed when the evaluation was designed: who would be in charge, through what mechanisms IMCI could affect child health, whether the focus would be efficacy or effectiveness, what indicators would be measured, what types of inference would be made, how costs would be incorporated, and what elements would constitute the plan of analysis. We describe how these questions were answered, the challenges encountered in implementing the evaluation, and the 5 study designs. The methodological insights gained can improve future evaluations of public health programs.

The Pelotas birth cohort study, Rio Grande do Sul, Brazil, 1982-2001.

Given the growing recognition of the importance of the life course approach for the determination of chronic diseases, birth cohort studies are becoming increasingly important. This paper describes the methods used in the 1982 Pelotas (Brazil) birth cohort study, one of the largest and longest studies of this type in developing countries. All 5,914 hospital births occurring in Pelotas in 1982 (over 99% of all deliveries) were studied prospectively. The main stages of the study took place in 1983, 1984, 1986, 1995, 1997, 2000, and 2001. More than two thousand variables are available for each subject who participated in all stages of the study. Recent phases of the study included the examination of 2,250 males when presenting for the army recruitment exam in 2000, the study of a 27% sample of men and women in 2001 through household visits, and the study of over 400 children born to the cohort women. Follow-up rates in the recent stages of the cohort were 78.9% for the army examination and 69.0% for the household visits. Ethnographic and oral health studies were conducted in sub-samples. Some recent results on blood pressure, adolescent pregnancy, and asthma are presented as examples of utilization of the data. Suggestions on lessons learned for other cohort studies are proposed.

The Pelotas birth cohort study, Rio Grande do Sul, Brazil, 1982-2001

Given the growing recognition of the importance of the life course approach for the determination of chronic diseases, birth cohort studies are becoming increasingly important. This paper describes the methods used in the 1982 Pelotas (Brazil) birth cohort study, one of the largest and longest studies of this type in developing countries. All 5,914 hospital births occurring in Pelotas in 1982 (over 99 percent of all deliveries) were studied prospectively. The main stages of the study took place in 1983, 1984, 1986, 1995, 1997, 2000, and 2001. More than two thousand variables are available for each subject who participated in all stages of the study. Recent phases of the study included the examination of 2,250 males when presenting for the army recruitment exam in 2000, the study of a 27 percent sample of men and women in 2001 through household visits, and the study of over 400 children born to the cohort women. Follow-up rates in the recent stages of the cohort were 78.9 percent for the army examination and 69.0 percent for the household visits. Ethnographic and oral health studies were conducted in sub-samples. Some recent results on blood pressure, adolescent pregnancy, and asthma are presented as examples of utilization of the data. Suggestions on lessons learned for other cohort studies are proposed

Effect of zinc supplementation started during diarrhoea on morbidity and mortality in Bangladeshi children: community randomised trial.

OBJECTIVE: To evaluate the effect on morbidity and mortality of providing daily zinc for 14 days to children with diarrhoea. DESIGN: Cluster randomised comparison. SETTING: Matlab field site of International Center for Diarrhoeal Disease Research, Bangladesh. PARTICIPANTS: 8070 children aged 3-59 months contributed 11 881 child years of observation during a two year period. INTERVENTION: Children with diarrhoea in the intervention clusters were treated with zinc (20 mg per day for 14 days); all children with diarrhoea were treated with oral rehydration therapy. MAIN OUTCOME MEASURES: Duration of episode of diarrhoea, incidence of diarrhoea and acute lower respiratory infections, admission to hospital for diarrhoea or acute lower respiratory infections, and child mortality. RESULTS: About 40% (399/1007) of diarrhoeal episodes were treated with zinc in the first four months of the trial; the rate rose to 67% (350/526) in month 5 and to >80% (364/434) in month 7 and was sustained at that level. Children from the intervention cluster received zinc for about seven days on average during each episode of diarrhoea. They had a shorter duration (hazard ratio 0.76, 95% confidence interval 0.65 to 0.90) and lower incidence of diarrhoea (rate ratio 0.85, 0.76 to 0.96) than children in the comparison group. Incidence of acute lower respiratory infection was reduced in the intervention group but not in the comparison group. Admission to hospital of children with diarrhoea was lower in the intervention group than in the comparison group (0.76, 0.59 to 0.98). Admission for acute lower respiratory infection was lower in the intervention group, but this was not statistically significant (0.81, 0.53 to 1.23). The rate of non-injury deaths in the intervention clusters was considerably lower (0.49, 0.25 to 0.94). CONCLUSIONS: The lower rates of child morbidity and mortality with zinc treatment represent substantial benefits from a simple and inexpensive intervention that can be incorporated in existing efforts to control diarrhoeal disease.

Cost-effectiveness of community health workers in tuberculosis control in Bangladesh.

OBJECTIVE: To compare the cost-effectiveness of the tuberculosis (TB) programme run by the Bangladesh Rural Advancement Committee (BRAC), which uses community health workers (CHWs), with that of the government TB programme which does not use CHWs. METHODS: TB control statistics and cost data for July 1996 - June 1997 were collected from both government and BRAC thanas (subdistricts) in rural Bangladesh. To measure the cost per patient cured, total costs were divided by the total number of patients cured. FINDINGS: In the BRAC and government areas, respectively, a total of 186 and 185 TB patients were identified over one year, with cure rates among sputum-positive patients of 84% and 82%. However, the cost per patient cured was US$ 64 in the BRAC area compared to US$ 96 in the government area. CONCLUSION: The government programme was 50% more expensive for similar outcomes. Although both the BRAC and government TB control programmes appeared to achieve satisfactory cure rates using DOTS (a five-point strategy), the involvement of CHWs was found to be more cost-effective in rural Bangladesh. With the same budget, the BRAC programme could cure three TB patients for every two in the government programme.

Estudo longitudinal da populaçäo materno-infantil da regiäo urbana do Sul do Brasil, 1993: aspectos metodológicos e resultados preliminares / Longitudinal study of the mother and child population in an urban region of southern Brazil, 1993: methodological aspects and preliminary results

Em 1982, todos os nascimentos ocorridos na cidade de Pelotaas, RS - Brasil, foram estudados e essas crianças foram acompanhadas prospectivamente durante os primeiros anos de vida. Em 1993, repetiu-se o estudo com metodologia similar, com a finalidade de avaliar as eventuais mudanças no nível de saúde materno-infantil, ocorridas durante esses onze anos. Todas as cinco maternidades da cidade foram visitadas diariamente e os 5.304 nascimentos ocorridos foram incluídos no estudo. As crianças foram pesadas e medidas, sendo sua idade gestacional avaliada através do método de Dubowitz. As mäes foram examinadas e entrevistadas sobre um grande número de fatores de risco. A mortalidade dessas crianças foi monitorizada por visitas regulares a hospitais, cemitérios e registros de óbito, e todas as internaçöes hospitalares foram acompanhadas. Dois estudos aninhados de casos e controles foram realizados para investigar fatores de risco para mortalidade e hospitalizaçöes. Uma amostra sistemática de 655 crianças foram examinadas em casa com um e três meses de idade, e essas mesmas crianças, acrescidas de outras 805 (que incluíram todos os recém-nascidos de baixo peso) foram também acompanhadas aos seis e doze meses de idade. O desenvolvimento psicomotor dessas amostras foi também avaliado. As perdas de acompanhamento aos doze meses foram de apenas 6,6 por cento. Em relaçäo aos dados de 1982, a pesquisa de 1993 mostrou reduçäo de cerca de 30 por cento na mortalidade perinatal e de quase 50 por cento na mortalidade infantil, assim como aumento de um mês na duraçäo mediana da amamentaçäo. Por outro lado, näo houve qualquer alteraçäo nas prevalências de baixo peso ao nascer e de déficit de comprimento/idade aos doze meses. O artigo a que se refere este resumo descreve a metodologia do estudo, ao qual se segue uma série de outras publicaçöes

Tendências e diferenciais na saúde materno-infantil: delineamento e metodologia das coortes de 1982 e 1993 de mäes e crianças de Pelotas, Rio Grande do Sul / Trends and defferentials in maternal and child health: design and metodology of the 1982 and 1993 birth cohort studies in Pelotas, Rio Grande do Sul

Mudanças ocorridas na última década em termos econômicos e assistenciais podem haver afetado a saúde materno-infantil. Dois estudos foram realizados em Pelotas, Rio Grande do Sul. As coortes de mäes e recém-nascidos noa anos de 1982 e 1993 foram estudadas desde o nascimento. As mäes foram identificadas nos hospitais-maternidade e responderam a um questionário padronizado sendo seus filhos examinados. Mais de 99 por cento dos recém-nascidos foram incluídos nas coortes, totalizando 5914 nascidos vivos em 1982 e 5249 em 1993. A mortalidade das crianças foi monitorizada, e em 1993 as hospitalizaçoes também o foram. Em 1982, tentou-se localizar cerca de 25 por cento das crianças aos 12 meses de idade e todas com a idade média de vinte meses. Foi possível encontrar cerca de 82 por cento das crianças aos 12 meses e, graças a uma mudança de estratégia, 87 por cento aos vinte meses. Em 1993, tentou-se acompanhar 20 por cento das crianças e mais todos os recém-nascidos de baixo peso aos 12 meses de idade, sendo 95 por cento localizados. Descreve os principais aspectos metodológicos de ambos os estudos, cujos principais resultados estäo incluídos nos próximos artigos desse suplemento.

Investigaciones sobre servicios de salud: una antologia / Health services research: an anthology

Estudo sobre assistência perinatal destinado a examinar os padröes de utilizaçäo dos serviços de atençäo à saúde de que dispöem as mulheres pertencentes a distintos grupos sociais e expostas a diferentes riscos da gestaçäo. Discute alguns resultados do estudo epidemiológico realizado em Pelotas em 1982, que permitiram investigar os fatores determinantes dos padröes de utilizaçäo dos serviços de atençäo à saúde, especialmente sobre a prática de cesáreas

Manuel d' épidémiologie pour la gestion de la santé au niveau du district / sous la direction de J. P. Vaughan et R. H. Morrow / Manual of epidemiology for district health management / Salud comunitaria : manual de la epidemiología para la gestión de servicios locales de salud SILOS

Cet ouvrage répond au besoin d'un guide simple, pratique, progressif sur l'utilisation de l'épidémiologie en tant qu'outil destiné à améliorer la gestion des services de santé. A l'intention des agents de santé généraux, ce livre utilise des définitions claires, des analogies, des exemples, des listes de contrôle, des formules et des calculs d'échantillons ainsi que d'abondantes illustrations pour démystifier les méthodes épidémiologiques et montrer comment elles peuvent s'appliquer dans des situations concrètes. L'accent porte sur les connaissances et les compétences simples requises pour recueillir puis utiliser les données épidémiologiques permettant de surveiller les problèmes de santé constants dans les pays en développement. Le livre s'achève sur une série de six annexes contenant des détails supplémentaires sur les méthodes exposées dans le manuel. Après une liste des principes éthiques à suivre dans les enquêtes épidémiologiques, on trouve comment évaluer la taille d'un échantillon destiné à une étude de prévalence, utiliser les nombres aléatoires, organiser une enquête épidémiologique, évaluer la validité et la valeur prédictive des examens de diagnostic et de dépistage et utiliser les taux spécifiques par âge et la standardisation directe par rapport à l'âge pour éviter des conclusions erronées