Eliana Jimenez-Soto

Equity and geography: the case of child mortality in Papua New Guinea.

Background Recent assessments show continued decline in child mortality in Papua New Guinea (PNG), yet complete subnational analyses remain rare. This study aims to estimate under-five mortality in PNG at national and subnational levels to examine the importance of geographical inequities in health outcomes and track progress towards Millennium Development Goal (MDG) 4. Methodology We performed retrospective data validation of the Demographic and Health Survey (DHS) 2006 using 2000 Census data, then applied advanced indirect methods to estimate under-five mortality rates between 1976 and 2000. Findings The DHS 2006 was found to be unreliable. Hence we used the 2000 Census to estimate under-five mortality rates at national and subnational levels. During the period under study, PNG experienced a slow reduction in national under-five mortality from approximately 103 to 78 deaths per 1,000 live births. Subnational analyses revealed significant disparities between rural and urban populations as well as inter- and intra-regional variations. Some of the provinces that performed the best (worst) in terms of under-five mortality included the districts that performed worst (best), with district-level under-five mortality rates correlating strongly with poverty levels and access to services. Conclusions The evidence from PNG demonstrates substantial within-province heterogeneity, suggesting that under-five mortality needs to be addressed at subnational levels. This is especially relevant in countries, like PNG, where responsibility for health services is devolved to provinces and districts. This study presents the first comprehensive estimates of under-five mortality at the district level for PNG. The results demonstrate that for countries that rely on few data sources even greater importance must be given to the quality of future population surveys and to the exploration of alternative options of birth and death surveillance.

What Works? Strategies to Increase Reproductive, Maternal and Child Health in Difficult to Access Mountainous Locations: A Systematic Literature Review

Background Geography poses serious challenges to delivery of health services and is a well documented marker of inequity. Maternal, newborn and child health (MNCH) outcomes are poorer in mountainous regions of low and lower-middle income countries due to geographical inaccessibility combined with other barriers: poorer quality services, persistent cultural and traditional practices and lower socioeconomic and educational status. Reaching universal coverage goals will require attention for remote mountain settings. This study aims to identify strategies to address barriers to reproductive MNCH (RMNCH) service utilisation in difficult-to-reach mountainous regions in low and lower-middle income settings worldwide. Methods A systematic literature review drawing from MEDLINE, Web of Science, Scopus, Google Scholar, and Eldis. Inclusion was based on; testing an intervention for utilisation of RMNCH services; remote mountain settings of low- and lower-middle income countries; selected study designs. Studies were assessed for quality and analysed to present a narrative review of the key themes. Findings From 4,130 articles 34 studies were included, from Afghanistan, Bolivia, Ethiopia, Guatemala, Indonesia, Kenya, Kyrgyzstan, Nepal, Pakistan, Papua New Guinea and Tajikistan. Strategies fall into four broad categories: improving service delivery through selected, trained and supported community health workers (CHWs) to act alongside formal health workers and the distribution of critical medicines to the home; improving the desirability of existing services by addressing the quality of care, innovative training and supervision of health workers; generating demand by engaging communities; and improving health knowledge for timely care-seeking. Task shifting, strengthened roles of CHWs and volunteers, mobile teams, and inclusive structured planning forums have proved effective. Conclusions The review highlights where known evidence-based strategies have increased the utilisation of RMNCH services in low income mountainous areas. While these are known strategies in public health, in such disadvantaged settings additional supports are required to address both supply and demand barriers.

Assessing the Poverty Impacts of Migrants’ Remittances Using Propensity Score Matching: The Case of Tonga

We estimate the impacts of remittances on poverty in Tonga, a poor Pacific island country highly dependent on migrants’ remittances. Using household survey data, we apply Propensity Score Matching (PSM) to estimate without-remittances incomes of migrant households from which counterfactual poverty rates are derived. We compare these with poverty rates from observed income including remittances to gauge their effects on poverty. We find that remittances reduce the incidence of poverty by 31 per cent and depth of poverty by 49 per cent. The results are robust both to alternative specifications of the PSM model and to use of an alternative counterfactual income estimation method.

Stagnant Neonatal Mortality and Persistent Health Inequality in Middle-Income Countries: A Case Study of the Philippines.

Background The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country’s socioeconomic-related child health inequality. Methodology Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality. Findings Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery. Conclusion The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality – that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system – to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.

How does progress towards the MDG 4 affect inequalities between different subpopulations? Evidence from Nepal

Background Few previous studies have examined non-wealth-based inequalities in child mortality within developing countries. This study estimates changes in under-5-year-olds and neonatal mortality in Nepal across a range of subnational levels, which allows us to assess the degree of equity in Nepals progress towards Millennium Development Goal 4. Methods Direct estimates of under-5-year-olds and neonatal death rates were generated for 1990–2005 using three Demographic and Health Surveys and two Living Standards Surveys by the following levels: national, rural/urban location, ecological region, development region, ethnicity and wealth. Absolute and relative inequalities were measured by rate differences and rate ratios, respectively. Additionally, wealth-related inequality was calculated using slope and relative indexes of inequality and concentration indices. Results Estimates suggest that while most rates of under-5-year-olds and neonatal mortality have declined across the different equity markers, leading to a downward trend in absolute inequalities, relative inequalities appear to have remained stable over time. The decline in absolute inequalities is strongest for under-5-year-olds’ mortality, with no statistically significant trend in either relative or absolute inequalities found for neonatal mortality. A possible increase in inequalities, at least in relative terms, was found across development regions, where death rates remain high in the mid-western region. Conclusions By 2015, our estimates suggest that more than 65% of deaths of under-5-year-olds will occur in the neonatal period, with stable trends in neonatal mortality inequalities. These findings along with the fact that health outcomes for neonates are more highly dependent on health systems, suggest further equitable reductions in under-5-year-olds mortality will require broad health-system strengthening, with a focus on the improvement of healthcare services provided for mothers and newborns. Other inequities suggest continued special attention for vulnerable subpopulations is warranted, particularly to overcome social exclusion and financial barriers to care in urban areas.

Are Australian smokers interested in using low-nitrosamine smokeless tobacco for harm reduction?

Aims To determine (1) whether Australian smokers are aware of low-nitrosamine smokeless tobacco (LNSLT) products and (2) whether they would be interested in using LNSLT either as a long-term substitute for smoking or as an aid to quitting, if these products were to become legally available. Methods 401 daily smokers were recruited by a market research company to complete an internet questionnaire about their smoking history, knowledge of smokeless tobacco and intentions to purchase LNSLT under different scenarios. Findings Just under half (48%) indicated they were willing to buy an LNSLT product. Predictors of an interest in purchasing LNSLT were low income, poorer health, prior SLT use, belief that SLT is less harmful than cigarettes, switching to a lower tar cigarette in the past year, ever using nicotine replacement therapy products for quitting or other reasons, having made a failed cessation attempt in the previous year and not planning to quit smoking. Analysis of quitting and LNSLT purchasing intentions under different scenarios suggest that making LNSLT available at a much lower cost than smoked cigarettes while increasing taxes on cigarettes could provide a greater reduction in the number of smokers than the same tax increase alone. These results support further examination of the potential for LNSLT to reduce smoking-related harm in Australia.

Disparities in child mortality trends: what is the evidence from disadvantaged states in India? the case of Orissa and Madhya Pradesh.

IntroductionThe Millennium Development Goals prompted renewed international efforts to reduce under-five mortality and measure national progress. However, scant evidence exists about the distribution of child mortality at low sub-national levels, which in diverse and decentralized countries like India are required to inform policy-making. This study estimates changes in child mortality across a range of markers of inequalities in Orissa and Madhya Pradesh, two of India’s largest, poorest, and most disadvantaged states.MethodsEstimates of under-five and neonatal mortality rates were computed using seven datasets from three available sources – sample registration system, summary birth histories in surveys, and complete birth histories. Inequalities were gauged by comparison of mortality rates within four sub-state populations defined by the following characteristics: rural–urban location, ethnicity, wealth, and district.ResultsTrend estimates suggest that progress has been made in mortality rates at the state levels. However, reduction rates have been modest, particularly for neonatal mortality. Different mortality rates are observed across all the equity markers, although there is a pattern of convergence between rural and urban areas, largely due to inadequate progress in urban settings. Inter-district disparities and differences between socioeconomic groups are also evident.ConclusionsAlthough child mortality rates continue to decline at the national level, our evidence shows that considerable disparities persist. While progress in reducing under-five and neonatal mortality rates in urban areas appears to be levelling off, polices targeting rural populations and scheduled caste and tribe groups appear to have achieved some success in reducing mortality differentials. The results of this study thus add weight to recent government initiatives targeting these groups. Equitable progress, particularly for neonatal mortality, requires continuing efforts to strengthen health systems and overcome barriers to identify and reach vulnerable groups.

Supporting local planning and budgeting for maternal, neonatal and child health in the Philippines.

BackgroundResponsibility for planning and delivery of health services in the Philippines is devolved to the local government level. Given the recognised need to strengthen capacity for local planning and budgeting, we implemented Investment Cases (IC) for Maternal, Neonatal and Child Health (MNCH) in three selected sub-national units: two poor, rural provinces and one highly-urbanised city. The IC combines structured problem-solving by local policymakers and planners to identify key health system constraints and strategies to scale-up critical MNCH interventions with a decision-support model to estimate the cost and impact of different scaling-up scenarios.MethodsWe outline how the initiative was implemented, the aspects that worked well, and the key limitations identified in the sub-national application of this approach.ResultsLocal officials found the structured analysis of health system constraints helpful to identify problems and select locally appropriate strategies. In particular the process was an improvement on standard approaches that focused only on supply-side issues. However, the lack of data available at the local level is a major impediment to planning. While the majority of the strategies recommended by the IC were incorporated into the 2011 plans and budgets in the three study sites, one key strategy in the participating city was subsequently reversed in 2012. Higher level systemic issues are likely to have influenced use of evidence in plans and budgets and implementation of strategies.ConclusionsEfforts should be made to improve locally-representative data through routine information systems for planning and monitoring purposes. Even with sound plans and budgets, evidence is only one factor influencing investments in health. Political considerations at a local level and issues related to decentralisation, influence prioritisation and implementation of plans. In addition to the strengthening of capacity at local level, a parallel process at a higher level of government to relieve fund channelling and coordination issues is critical for any evidence-based planning approach to have a significant impact on health service delivery.

Location matters: trends in inequalities in child mortality in Indonesia. Evidence from repeated cross-sectional surveys

Background Considerable improvements in life expectancy and other human development indicators in Indonesia are thought to mask considerable disparities between populations in the country. We examine the existence and extent of these disparities by measuring trends and inequalities in the under-five mortality rate and neonatal mortality rate across wealth, education and geography. Methodology Using data from seven waves of the Indonesian Demographic and Health Surveys, direct estimates of under-five and neonatal mortality rates were generated for 1980–2011. Absolute and relative inequalities were measured by rate differences and ratios, and where possible, slope and relative indices of inequality. Disparities were assessed by levels of rural/urban location, island groups, maternal education and household wealth. Findings Declines in national rates of under-five and neonatal mortality have accorded with reductions of absolute inequalities in clusters stratified by wealth, maternal education and rural/urban location. Across these groups, relative inequalities have generally stabilised, with possible increases with respect to mortality across wealth subpopulations. Both relative and absolute inequalities in rates of under-five and neonatal mortality stratified by island divisions have widened. Conclusion Indonesia has made considerable gains in reducing under-five and neonatal mortality at a national level, with the largest reductions happening before the Asian financial crisis (1997–98) and decentralisation (2000). Hasty implementation of decentralisation reforms may have contributed to a slowdown in mortality rate reduction thereafter. Widening inequities between the most developed provinces of Java-Bali and those of other island groupings should be of particular concern for a country embarking on an ambitious plan for universal health coverage by 2019. A focus on addressing the key supply side barriers to accessing health care and on the social determinants of health in remote and disadvantaged regions will be essential for this plan to be realised.

A Framework for the Economic Analysis of Data Collection Methods for Vital Statistics

Background Over recent years there has been a strong movement towards the improvement of vital statistics and other types of health data that inform evidence-based policies. Collecting such data is not cost free. To date there is no systematic framework to guide investment decisions on methods of data collection for vital statistics or health information in general. We developed a framework to systematically assess the comparative costs and outcomes/benefits of the various data methods for collecting vital statistics. Methodology The proposed framework is four-pronged and utilises two major economic approaches to systematically assess the available data collection methods: cost-effectiveness analysis and efficiency analysis. We built a stylised example of a hypothetical low-income country to perform a simulation exercise in order to illustrate an application of the framework. Findings Using simulated data, the results from the stylised example show that the rankings of the data collection methods are not affected by the use of either cost-effectiveness or efficiency analysis. However, the rankings are affected by how quantities are measured. Conclusion There have been several calls for global improvements in collecting useable data, including vital statistics, from health information systems to inform public health policies. Ours is the first study that proposes a systematic framework to assist countries undertake an economic evaluation of DCMs. Despite numerous challenges, we demonstrate that a systematic assessment of outputs and costs of DCMs is not only necessary, but also feasible. The proposed framework is general enough to be easily extended to other areas of health information.