Margaret E. Kruk

Global health 2035: a world converging within a generation

Prompted by the 20th anniversary of the 1993 World Development Report a Lancet Commission revisited the case for investment in health and developed a new investment frame work to achieve dramatic health gains by 2035. The report has four key messages each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. Conclusion 1: there is a very large payoff from investing in health. Conclusion 2: a grand convergence is achievable within our lifetime. Conclusion 3: scale-up of low-cost packages of interventions can enable major progress in NCDs and injuries within a generation. Conclusion 4: progressive universalism is an effi cient way to achieve health and fi nancial protection.

Women's preferences for place of delivery in rural Tanzania: a population-based discrete choice experiment.

OBJECTIVES We fielded a population-based discrete choice experiment (DCE) in rural western Tanzania, where only one third of women deliver children in a health facility, to evaluate health-system factors that influence womens delivery decisions. METHODS Women were shown choice cards that described 2 hypothetical health centers by means of 6 attributes (distance, cost, type of provider, attitude of provider, drugs and equipment, free transport). The women were then asked to indicate which of the 2 facilities they would prefer to use for a future delivery. We used a hierarchical Bayes procedure to estimate individual and mean utility parameters. RESULTS A total of 1203 women completed the DCE. The model showed good predictive validity for actual facility choice. The most important facility attributes were a respectful provider attitude and availability of drugs and medical equipment. Policy simulations suggested that if these attributes were improved at existing facilities, the proportion of women preferring facility delivery would rise from 43% to 88%. CONCLUSIONS In regions in which attended delivery rates are low despite availability of primary care facilities, policy experiments should test the effect of targeted quality improvements on facility use.

Borrowing And Selling To Pay For Health Care In Low-And Middle-Income Countries

Many families around the world make sizable out-of-pocket payments for health care. We calculated the frequency of borrowing money or selling assets to buy health services in forty low- and middle-income countries and estimated how various factors are associated with these coping strategies. The data represented a combined population of 3.66 billion, or 58 percent of the worlds population. On average, 25.9 percent of households borrowed money or sold items to pay for health care. The risk was higher among the poorest households and in countries with less health insurance. Health systems in developing countries are failing to protect families from the financial risks of seeking health care.

Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania

In an effort to reduce maternal mortality, developing countries have been investing in village-level primary care facilities to bring skilled delivery services closer to women. We explored the extent to which women in rural western Tanzania bypass their nearest primary care facilities to deliver at more distant health facilities, using a population-representative survey of households (N = 1204). Using a standardized instrument, we asked women who had a delivery within 5 years about the place of their most recent delivery. Information on all functioning health facilities in the area were obtained from the district health office. Women who delivered in a health facility that was not the nearest available facility were considered bypassers. Forty-four per cent (186/423) of women who delivered in a health facility bypassed their nearest facility. In adjusted analysis, women who bypassed were more likely than women who did not bypass to be 35 or older (OR 2.5, P </= 0.01), to have one or no living children (OR 2.2, P = 0.03), to have stayed in a maternity waiting home prior to delivery (OR 4.3, P </= 0.01), to choose a facility on the basis of quality or experience (OR 2.1, P </= 0.01), to have a high level of trust in health workers at the delivery facility (OR 2.7, P </= 0.01), and to perceive the nearest facility to be of low quality (OR 3.1, P </= 0.01). Bypassing for facility delivery is frequent among women in rural Tanzania. In addition to obstetric risk factors, a major reason for this appears to be a concern about the quality of care at government dispensaries and health centres. Investing in improved quality of care in primary care facilities may reduce bypassing and improve the efficiency and effectiveness of the health system in providing coverage for facility delivery in rural Africa.

The contribution of primary care to health and health systems in low- and middle-income countries: A critical review of major primary care initiatives

It has been 30 years since the Declaration of Alma Ata. During that time, primary care has been the central strategy for expanding health services in many low- and middle-income countries. The recent global calls to redouble support for primary care highlighted it as a pathway to reaching the health Millennium Development Goals. In this systematic review we described and assessed the contributions of major primary care initiatives implemented in low- and middle-income countries in the past 30 years to a broad range of health system goals. The scope of the programs reviewed was substantial, with several interventions implemented on a national scale. We found that the majority of primary care programs had multiple components from health service delivery to financing reform to building community demand for health care. Although given this integration and the variable quality of the available research it was difficult to attribute effects to the primary care component alone, we found that primary care-focused health initiatives in low- and middle-income countries have improved access to health care, including among the poor, at reasonably low cost. There is also evidence that primary care programs have reduced child mortality and, in some cases, wealth-based disparities in mortality. Lastly, primary care has proven to be an effective platform for health system strengthening in several countries. Future research should focus on understanding how to optimize the delivery of primary care to improve health and achieve other health system objectives (e.g., responsiveness, efficiency) and to what extent models of care can be exported to different settings.

Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique

Objective  To compare the training and deployment costs and surgical productivity of surgically trained assistant medical officers (técnicos de cirurgia) and specialist physicians (surgeons and obstetrician/gynaecologists) in Mozambique in order to inform health human resource planning in a developing country with low availability of obstetric care and severe physician shortages. Técnicos de cirurgia have been previously shown to have quality of care outcomes comparable to physicians.

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey.

In the second of two papers investigating surgical provision in eight district hospitals in Saharan African countries, Margaret Kruk and colleagues describe the range of providers of surgical care and anesthesia and estimate the related costs.

Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group.

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.

Rebuilding health systems to improve health and promote statebuilding in post-conflict countries: A theoretical framework and research agenda

Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.

User fee exemptions are not enough: out-of-pocket payments for 'free' delivery services in rural Tanzania

Objective  To identify the main drivers of costs of facility delivery and the financial consequences for households among rural women in Tanzania, a country with a policy of delivery fee exemptions.