Rachel Tolhurst

Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part 1: determinants operating at individual and household level

A high burden of malaria, tuberculosis, and HIV infection contributes to national and individual poverty. We have reviewed a broad range of evidence detailing factors at individual, household, and community levels that influence vulnerability to malaria, tuberculosis, and HIV infection and used this evidence to identify strategies that could improve resilience to these diseases. This first part of the review explores the concept of vulnerability to infectious diseases and examines how age, sex, and genetics can influence the biological response to malaria, tuberculosis, and HIV infection. We highlight factors that influence processes such as poverty, livelihoods, gender discrepancies, and knowledge acquisition and provide examples of how approaches to altering these processes may have a simultaneous effect on all three diseases.

Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part II: determinants operating at environmental and institutional level

This review summarises a wide range of evidence about environmental and institutional factors that influence vulnerability to malaria, tuberculosis, and HIV infection. By combining this information with that obtained on factors operating at individual, household, and community level, we have identified potential common strategies for improving resilience to all three diseases simultaneously. These strategies depend on collaborations with non-health sectors and include progress in rapid access to funds, provision of education about disease transmission and management, reduction of the burden on carers (predominantly women), and improvement in the quality of health services.

How does the new cooperative medical scheme influence health service utilization? A study in two provinces in rural China.

BackgroundMany countries are developing health financing mechanisms to pursue the goal of universal coverage. In China, a rural health insurance system entitled New Cooperative Medical Scheme (NCMS) is being developed since 2003. Although there is concern about whether the NCMS will influence the serious situation of inequity in health service utilization in rural China, there is only limited evidence available. This paper aims to assess the utilisation of outpatient and inpatient services among different income groups and provinces under NCMS in rural China.MethodsUsing multistage sampling processes, a cross-sectional household survey including 6,147 rural households and 22,636 individuals, was conducted in six counties in Shandong and Ningxia Provinces, China. Chi-square test, Poisson regression and log-linear regression were applied to analyze the association between NCMS and the utilization of outpatient and inpatient services and the length of stay for inpatients. Qualitative methods including individual interview and focus group discussion were applied to explain and complement the findings from the household survey.ResultsNCMS coverage was 95.9% in Shandong and 88.0% in Ningxia in 2006. NCMS membership had no significant association with outpatient service utilization regardless of income level and location.Inpatient service utilization has increased for the high income group under NCMS, but for the middle and low income, the change was not significant. Compared with non-members, NCMS members from Ningxia used inpatient services more frequently, while members from Shandong had a longer stay in hospital.High medical expenditure, low reimbursement rate and difference in NCMS policy design between regions were identified as the main reasons for the differences in health service utilization.ConclusionsOutpatient service utilization has not significantly changed under NCMS. Although utilization of inpatient service in general has increased under NCMS, people with high income tend to benefit more than the low income group. While providing financial protection against catastrophic medical expenditure is the principal focus of NCMS, this study recommends that outpatient services should be incorporated in future NCMS policy development. NCMS policy should also be more equity oriented to achieve its policy goal.

Traditional beliefs and practices in the postpartum period in Fujian Province, China: a qualitative study

BackgroundZuo yuezi is the month postpartum in China associated with a variety of traditional beliefs and practices. We explored the current status of zuo yuezi from social, cultural and western medical perspectives.MethodsWe interviewed family members (36) and health workers (8) in Fujian Province, selecting one rural and one rapidly developing urban county. We asked about their traditional beliefs and their behaviour postpartum. We used a framework approach to identify main themes. We categorised reported behaviour against their probable effects on health, drawing on Western standards.ResultsRespondents reported that zuo yuezi was commonly practiced in urban and rural families to help the mother regain her strength and protect her future health. Zuo yuezi included: dietary precautions, such as eating more food and avoiding cold food; behavioural precautions, such as staying inside the home, avoiding housework and limiting visitors; hygiene precautions, such as restricting bathing and dental hygiene; and practices associated with infant feeding, including supplementary feeding and giving honeysuckle herb to the infant. Respondents reported that the main reasons for adhering to these practices were respect for tradition, and following the advice of elders. Categorised against Western medical standards, several zuo yuezi practices are beneficial, including eating more, eating protein rich food, avoiding housework, and daily vulval and perineal hygiene. A few are potentially harmful, including giving honeysuckle herb, and avoiding dental hygiene. Some women reported giving infants supplementary feeds, although zuo yuezi emphasises breast feeding.ConclusionZuo yuezi is an important ritual in Fujian. In medical terms, most practices are beneficial, and could be used by health staff to promote health in this period. Further research on reported potentially harmful practices, such as supplements to breast feeding, is needed.

Going beyond the surface: Gendered intra-household bargaining as a social determinant of child health and nutrition in low and middle income countries

A growing body of research highlights the importance of gendered social determinants of child health, such as maternal education and womens status, for mediating child survival. This narrative review of evidence from diverse low and middle-income contexts (covering the period 1970-May 2012) examines the significance of intra-household bargaining power and process as gendered dimensions of child health and nutrition. The findings focus on two main elements of bargaining: the role of womens decision-making power and access to and control over resources; and the importance of household headship, structure and composition. The paper discusses the implications of these findings in the light of lifecycle and intersectional approaches to gender and health. The relative lack of published intervention studies that explicitly consider gendered intra-household bargaining is highlighted. Given the complex mechanisms through which intra-household bargaining shapes child health and nutrition it is critical that efforts to address gender in health and nutrition programming are thoroughly documented and widely shared to promote further learning and action. There is scope to develop links between gender equity initiatives in areas of adult and adolescent health, and child health and nutrition programming. Child health and nutrition interventions will be more effective, equitable and sustainable if they are designed based on gender-sensitive information and continually evaluated from a gender perspective.

How effectively can the New Cooperative Medical Scheme reduce catastrophic health expenditure for the poor and non-poor in rural China?

Objectives  China has implemented the New Cooperative Medical Scheme (NCMS) in rural areas since 2003 to provide financial protection to its rural population. This article explores the effect of NCMS on relieving catastrophic health expenditure (CHE) among the poor and non‐poor groups.

What is quality in maternal and neonatal health care

OBJECTIVE to review published papers and reports examining quality of care in maternal and newborn health to identify definitions and models of quality of care. DESIGN literature review. SEARCH STRATEGY electronic search of MEDLINE and organisational databases for literature describing definitions and models of quality used in health care and maternal and newborn health care. Relevant papers and reports were reviewed and summarised. FINDINGS there is no universally accepted definition of quality of care. The multi-faceted nature of quality is widely acknowledged. In the literature quality of care is described: from the perspective of health care providers, managers and patients; dimensions within the health care system; using elements such as safety, effectiveness, patient-centeredness, timeliness, equity and efficiency; and through the provision of care and experience of care. KEY CONCLUSIONS the importance of ensuring good quality of care for women and newborn babies is well recognised in the literature, however, there is currently no agreed single and comprehensive definition described. Several models were identified, which can be combined to form a comprehensive framework to help define and assess quality of care or lack of quality. Approaches to quality of care that are specifically important for maternal and newborn health were identified and include a rights based approach, adopting care that is evidence-based, consideration of the mother and baby as interdependent and the fact that pregnancy is on the whole a healthy state. IMPLICATIONS FOR PRACTICE a model of quality of maternal and newborn health care using perspectives, characteristics, dimensions of the system and elements of quality of care specific to maternal and newborn health is proposed, which can be used as a basis for developing quality improvement strategies and activities, and incorporating quality into existing programmes.

How affordable are tuberculosis diagnosis and treatment in rural China? An analysis from community and tuberculosis patient perspectives

Objectives  To assess equity in access to tuberculosis (TB) care by estimating and comparing the direct household costs perceived by community residents with actual costs experienced by TB patients and to identify the factors influencing the financial burden of TB patients.

Treatment seeking for symptoms suggestive of TB: comparison between migrants and permanent urban residents in Chongqing, China

objectives To understand the health‐seeking behaviour of rural‐to‐urban migrants with chronic cough in Chongqing city, and compare this with the permanent urban population taking into account the socioeconomic factors influencing delays in access to healthcare in urban China.

Can rural health insurance improve equity in health care utilization? A comparison between China and Vietnam.

IntroductionHealth care financing reforms in both China and Vietnam have resulted in greater financial difficulties in accessing health care, especially for the rural poor. Both countries have been developing rural health insurance for decades. This study aims to evaluate and compare equity in access to health care in rural health insurance system in the two countries.MethodsHousehold survey and qualitative study were conducted in 6 counties in China and 4 districts in Vietnam. Health insurance policy and its impact on utilization of outpatient and inpatient service were analyzed and compared to measure equity in access to health care.ResultsIn China, Health insurance membership had no significant impact on outpatient service utilization, while was associated with higher utilization of inpatient services, especially for the higher income group. Health insurance members in Vietnam had higher utilization rates of both outpatient and inpatient services than the non-members, with higher use among the lower than higher income groups. Qualitative results show that bureaucratic obstacles, low reimbursement rates, and poor service quality were the main barriers for members to use health insurance.ConclusionsChina has achieved high population coverage rate over a short time period, starting with a limited benefit package. However, poor people have less benefit from NCMS in terms of health service utilization. Compared to China, Vietnam health insurance system is doing better in equity in health service utilization within the health insurance members. However with low population coverage, a large proportion of population cannot enjoy the health insurance benefit. Mutual learning would help China and Vietnam address these challenges, and improve their policy design to promote equitable and sustainable health insurance.