Rajesh Panjabi

Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review

A systematic review conducted by Sanjay Basu and colleagues reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries.

Association of Combatant Status and Sexual Violence With Health and Mental Health Outcomes in Postconflict Liberia

CONTEXT Liberias wars since 1989 have cost tens of thousands of lives and left many people mentally and physically traumatized. OBJECTIVES To assess the prevalence and impact of war-related psychosocial trauma, including information on participation in the Liberian civil wars, exposure to sexual violence, social functioning, and mental health. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional, population-based, multistage random cluster survey of 1666 adults aged 18 years or older using structured interviews and questionnaires, conducted during a 3-week period in May 2008 in Liberia. MAIN OUTCOME MEASURES Symptoms of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD), social functioning, exposure to sexual violence, and health and mental health needs among Liberian adults who witnessed or participated in the conflicts during the last 2 decades. RESULTS In the Liberian adult household-based population, 40% (95% confidence interval [CI], 36%-45%; n = 672/1659) met symptom criteria for MDD, 44% (95% CI, 38%-49%; n = 718/1661) met symptom criteria for PTSD, and 8% (95% CI, 5%-10%; n = 133/1666) met criteria for social dysfunction. Thirty-three percent of respondents (549/1666) reported having served time with fighting forces, and 33.2% of former combatant respondents (182/549) were female. Former combatants experienced higher rates of exposure to sexual violence than noncombatants: among females, 42.3% (95% CI, 35.4%-49.1%) vs 9.2% (95% CI, 6.7%-11.7%), respectively; among males, 32.6% (95% CI, 27.6%-37.6%) vs 7.4% (95% CI, 4.5%-10.4%). The rates of symptoms of PTSD, MDD, and suicidal ideation were higher among former combatants than noncombatants and among those who experienced sexual violence vs those who did not. The prevalence of PTSD symptoms among female former combatants who experienced sexual violence (74%; 95% CI, 63%-84%) was higher than among those who did not experience sexual violence (44%; 95% CI, 33%-53%). The prevalence of PTSD symptoms among male former combatants who experienced sexual violence was higher (81%; 95% CI, 74%-87%) than among male former combatants who did not experience sexual violence (46%; 95% CI, 39%-52%). Male former combatants who experienced sexual violence also reported higher rates of symptoms of depression and suicidal ideation. Both former combatants and noncombatants experienced inadequate access to health care (33.0% [95% CI, 22.6%-43.4%] and 30.1% [95% CI, 18.7%-41.6%], respectively). CONCLUSIONS Former combatants in Liberia were not exclusively male. Both female and male former combatants who experienced sexual violence had worse mental health outcomes than noncombatants and other former combatants who did not experience exposure to sexual violence.

5-SPICE: the application of an original framework for community health worker program design, quality improvement and research agenda setting

Introduction Despite decades of experience with community health workers (CHWs) in a wide variety of global health projects, there is no established conceptual framework that structures how implementers and researchers can understand, study and improve their respective programs based on lessons learned by other CHW programs. Objective To apply an original, non-linear framework and case study method, 5-SPICE, to multiple sister projects of a large, international non-governmental organization (NGO), and other CHW projects. Design Engaging a large group of implementers, researchers and the best available literature, the 5-SPICE framework was refined and then applied to a selection of CHW programs. Insights gleaned from the case study method were summarized in a tabular format named the ‘5×5-SPICE chart’. This format graphically lists the ways in which essential CHW program elements interact, both positively and negatively, in the implementation field. Results The 5×5-SPICE charts reveal a variety of insights that come from a more complex understanding of how essential CHW projects interact and influence each other in their unique context. Some have been well described in the literature previously, while others are exclusive to this article. An analysis of how best to compensate CHWs is also offered as an example of the type of insights that this method may yield. Conclusions The 5-SPICE framework is a novel instrument that can be used to guide discussions about CHW projects. Insights from this process can help guide quality improvement efforts, or be used as hypothesis that will form the basis of a programs research agenda. Recent experience with research protocols embedded into successfully implemented projects demonstrates how such hypothesis can be rigorously tested. This paper is part of the thematic cluster Global Health Beyond 2015 - more papers from this cluster can be found at http://www.globalhealthaction.net

Remoteness and maternal and child health service utilization in rural Liberia: A population–based survey

Background This study seeks to understand distance from health facilities as a barrier to maternal and child health service uptake within a rural Liberian population. Better understanding the relationship between distance from health facilities and rural health care utilization is important for post–Ebola health systems reconstruction and for general rural health system planning in sub–Saharan Africa. Methods Cluster–sample survey data collected in 2012 in a very rural southeastern Liberian population were analyzed to determine associations between quartiles of GPS–measured distance from the nearest health facility and the odds of maternal (ANC, facility–based delivery, and PNC) and child (deworming and care seeking for ARI, diarrhea, and fever) service use. We estimated associations by fitting simple and multiple logistic regression models, with standard errors adjusted for clustered data. Findings Living in the farthest quartile was associated with lower odds of attending 1–or–more ANC checkup (AOR = 0.04, P < 0.001), 4–or–more ANC checkups (AOR = 0.13, P < 0.001), delivering in a facility (AOR = 0.41, P = 0.006), and postnatal care from a health care worker (AOR = 0.44, P = 0.009). Children living in all other quartiles had lower odds of seeking facility–based fever care (AOR for fourth quartile = 0.06, P < 0.001) than those in the nearest quartile. Children in the fourth quartile were less likely to receive deworming treatment (AOR = 0.16, P < 0.001) and less likely (but with only marginal statistical significance) to seek ARI care from a formal HCW (AOR = 0.05, P = 0.05). Parents in distant quartiles more often sought ARI and diarrhea care from informal providers. Conclusions Within a rural Liberian population, distance is associated with reduced health care uptake. As Liberia rebuilds its health system after Ebola, overcoming geographic disparities, including through further dissemination of providers and greater use of community health workers should be prioritized.

Community health worker programmes after the 2013–2016 Ebola outbreak

The 2013–2016 Ebola virus disease outbreak in West Africa exposed an urgent need to strengthen health surveillance and health systems in low-income countries, not only to improve the health of populations served by these health systems but also to promote global health security.1 Chronically fragile and under-resourced health systems2 enabled the initial outbreak in Guinea to spiral into an epidemic of over 28 616 cases and 11 310 deaths (as of 5 May 2016)3 in Guinea, Liberia and Sierra Leone, requiring an unprecedented global response that is still ongoing. Control efforts were hindered by gaps in the formal health system and by resistance from the community, fuelled by fear and poor communication. Lessons learnt from this Ebola outbreak have raised the question of how the affected countries, and other low-income countries with similarly weak health systems, can build stronger health systems and surveillance mechanisms to prevent future outbreaks from escalating.4 Factors that were important in the growth and persistence of the Ebola virus outbreak were lack of trust in the health system at the community level, the spread of misinformation, deeply embedded cultural practices conducive to transmission (e.g. burial customs), inadequate reporting of health events and the public’s lack of access to health services.1 Community health workers are in a unique position to mitigate these factors through surveillance for danger signs and mobilization of communities when an outbreak has been identified. In this paper we make the case for investing in robust national community health worker programmes as one of the strategies for improving global health security, for preventing future catastrophic infectious disease outbreaks and for strengthening health systems.

Implementation research on community health workers provision of maternal and child health services in rural Liberia.

Abstract Objective To assess changes in the use of essential maternal and child health services in Konobo, Liberia, after implementation of an enhanced community health worker (CHW) programme. Methods The Liberian Ministry of Health partnered with Last Mile Health, a nongovernmental organization, to implement a pilot CHW programme with enhanced recruitment, training, supervision and compensation. To assess changes in maternal and child health-care use, we conducted repeated cross-sectional cluster surveys before (2012) and after (2015) programme implementation. Findings Between 2012 and 2015, 54 CHWs, seven peer supervisors and three clinical supervisors were trained to serve a population of 12 127 people in 44 communities. The regression-adjusted percentage of children receiving care from formal care providers increased by 60.1 (95% confidence interval, CI: 51.6 to 68.7) percentage points for diarrhoea, by 30.6 (95% CI: 20.5 to 40.7) for fever and by 51.2 (95% CI: 37.9 to 64.5) for acute respiratory infection. Facility-based delivery increased by 28.2 points (95% CI: 20.3 to 36.1). Facility-based delivery and formal sector care for acute respiratory infection and diarrhoea increased more in agricultural than gold-mining communities. Receipt of one-or-more antenatal care sessions at a health facility and postnatal care within 24 hours of delivery did not change significantly. Conclusion We identified significant increases in uptake of child and maternal health-care services from formal providers during the pilot CHW programme in remote rural Liberia. Clinic-based services, such as postnatal care, and services in specific settings, such as mining areas, require additional interventions to achieve optimal outcomes.

Violence and the role of illness narratives

www.thelancet.com Vol 372 August 30, 2008 699 at radiation doses lower than amounts tradition ally considered inducible by direct changes in the exposed cells. Such fi ndings suggest non-targeted mechanisms could be associated with the development of radiation-related health eff ects. Atherosclerosis is a multifactorial disease, resulting from a lifelong interplay between genetic, environmental, and behavioural factors, which might be modifi ed by radiation exposure. The relative risk of cardiovascular disease associated with radiation dose is much smaller than that of radiation-associated cancer, which would have substantial public-health implications in view of the high background rates of cardiovascular disease. Because of the uncertainty in the magnitude and nature of cardiovascular disease risk at a low dose of radiation, estimation of the excess number of patients in an exposed population is premature. Further investigations are needed to sort out eff ects of radiation and confounders in existing and planned studies of radiation-exposed cohorts, and new laboratory studies are needed to explore biological mechanisms for low-dose radiation-related cardiovascular eff ects. The low-dose radiation eff ects on cardiovascular disease risk are likely to remain challenging and controversial—even more so than the linear no-threshold arguments for cancer risk that are debated to this day—but should not be dismissed. After writing this Comment, we learned about the recent death of Dave McGeoghegan. We are saddened by this news. The scientifi c community will miss this