The impact of health interventions and programmes on mortality

Maternal and child health programs are yet to achieve desired impact on the obstetric and newborn care services utilization from public-sector health facilities in Bangladesh. Home delivery and untrained providers largely contribute to the underutilization of the existing obstetric and newborn care services provided at facilities. Demand-side barriers particularly cost remains a key challenge to utilize MNCH care from facilities. This paper explore whether subsidized consumer cost increases utilization of obstetrics and newborn health service from facilities. Financial assistance in the form of coupon was provided to poor pregnant women to cover transportation and medical cost for receiving services from facilities. A rigorous process consisting of community assessment and use of poverty tool was employed to select eligible women. Three-fourths of the poor pregnant women were identified as eligible for coupon distribution from 20,833 pregnant women from 2 districts. Seventy nine percent coupons were utilized for receiving the ANC services followed by institutional delivery, PNC, and pregnancy complications care. The most cited reason for non-use of coupon is inadequate knowledge about the coupon and transportation cost. Round trip transportation costs and intensive advocacy at the community will increase the coupon use.

The purpose of this paper is to shed light on health inequalities among adult population in Thai Nguyen - a northern mountainous province of Vietnam. Using data from a population-based health survey in the province, the paper explores differences in self-reported health by ethnicity, gender, and household income. Multinomial logistic regressions are used to learn about relations between social determinants of health and self-reported health. The study provides clear evidence of the similarity in adult health status between ethnic minority and the Kinh or the ethnic majority. This finding suggests that policies targeting health improvement for ethnic minority should prioritize children rather than adult population. It consistently found that adult females have worse reported health than adult males. This study provide clear evidence of the social gradient in health: people in the lower income quintiles have worse health than those in the higher quintiles. The study revealed that the pro-poor program known as P135 has created positive effects on population health and such efforts should be continued. The near-poor was found as the most vulnerable population. While the line between poor and near-poor is fragile, this finding raises great concerns to the current pro-poor policies and motivation for the poor to move up the ladder.

Commonly, methods such as rate-ratios and rate-differentials are applied to assess inter-temporal, inter-regional and inter-group progress. However, an indiscriminate application of these methods is identified as an area for concern. In particular, rate-ratios are sensitive to the adopted definition of an indicator (achievement or failure) and tend to be larger (smaller) at lower (higher) overall levels. Clearly, they are effective only when considered along with overall levels and the adopted definition of the indicator. Also, it is critical that the progress is assessed both in terms of achievement and the effort toward achievement. Given such intricacies, this paper reviews the existing methods for progress assessment and discusses an alternative level-sensitive approach that informs regarding effort and offers similar conclusions irrespective of the adopted definition of the indicator. Data from the official MDG monitoring database is analysed to present an international comparison of achievements in reducing child and infant mortality rates.

This paper examines the impact of antenatal care (ANC) on neonatal mortality using nationally representative data from India. For the first time, we apply the WHO Framework of effective coverage to measure health systems performance of ANC. We define effective coverage by creating an “Ideal” package of ANC consisting of 10 key interventions, and also define “Less Than Ideal” packages comprising different combinations of less than the 10 interventions. Using data from over 60,000 mother-child dyads from 1998/9 and 2005/6 National Family Health Surveys of India, we use multivariable logistic regression models to examine the association of ANC on neonatal mortality.

We find that only 10.4% of Indian women received effective ANC. There is substantial socioeconomic variation, with a 10-fold difference in effective coverage between the richest and poorest wealth quintile. Effective coverage is significantly associated with a 51% reduction in the odds of neonatal mortality (OR: 0.49; 95% CI: 0.36-0.67). This “Ideal package is more protective against neonatal mortality than other “Less Than Ideal” packages.

India’s health system is not meeting the needs of pregnant women. Improving utilisation and delivery of the components of ANC to improve service quality, has important consequences for improving child health in India.

The childhood mortality may be vulnerable as many biological, environmental, social, cultural and behavioral factors have been responsible for structuring the patterns of mortality. The relation between first birth order and risk of child mortality is not well understood. Under the assumption there may be socio-demographic, behavioral, environment, etc factors behind this higher risk of mortality this study examines under-five aged child survival at first birth of the mother to identify the factors influence on child survival for policy suggestions. Using four rounds data set of the Bangladesh Demographic and Health Surveys (BDHS 1993-94, 1996-97, 1999-00 and 2004) binary logistic regression model shows that tetanus injection of mother before birth of the child is the most dominant determinant for the under-five aged first child survival; whereas educational attainment, antenatal visit for pregnancy before birth and tubewell as source of drinking water have had also impact with some variations. As higher education, access to antenatal visit and ensuring tetanus injection before pregnancy have had significant impact these should be taken into high consideration to accelerate further for child survival which will contribute to reduce mortality reduction as well. There are more scopes to examine other variables to understand child

In recent decades there has been a significant progress in child mortality decline around the world and this has been accompanied by important changes in the profile of causes of death. On one hand the levels of infant mortality rate (IMR) have fallen to 100 per thousand or less, and in some others cases these figures are similar to those observed in the developed world. On the other hand, there have been changes in the profile of causes: intestinal and respiratory infections have lost ground to perinatal conditions and congenital anomalies.
Despite these important advances there are still some outstanding issues in the effort to consolidate the decline in infant mortality. In particular, there are three points of interest:

1. Is infant mortality measured accurately?
2. Are vital statistics (VS) a reliable source for estimating IMR, or there is still a need to use the Brass technique to have reliable estimates?
3. How useful are the VS to ascertain the epidemiological profile of infant mortality?

This paper analyzes the situation (level and epidemiological profile) of infant mortality in several countries around the world using data from vital statistics and census information from the Integrated Public Use Microdata Series (IPUMS).

Three neonates are dying every minute in India and every 4th baby born is low birth weight out of 3.9 million neonatal deaths worldwide, India is accounting 1.2 million or nearly 30 percent of global neonatal mortality. In India 39 % of neonatal death occurs within 24 hour of the birth and 57.5% death occurs within first three days. The purpose of this study is to examine the effect of maternal health care utilization on early neonatal, neonatal and post neonatal mortality in India. Data from the cross –sectional, population based NFHS-3(2005-06) was used. Both bi-variate and multivariate techniques were used to examine the effect of antenatal care, safe delivery and post natal care on early neonatal, neonatal and post neonatal mortality. The result of the logistic regression shows that ante natal care has significant impact on early neonatal and neonatal mortality and it is also found that public hospital less relative risk than private sector deliveries. Those women who had taken the post natal care the risk of early neonatal, neonatal and post neonatal are less likely in comparison to those who not received the post natal care.

Early case detection and prompt treatment with artemisinin-based combination therapy (ACT) is one of the main malaria control strategies. The INDEPTH Network Effectiveness and Safety Studies on Antimalarials in Africa (INESS) was implemented in 7 Health and Demographic Surveillance Sites to identify bottlenecks of the ACT efficacy decay. This presentation will share findings on the systems effectiveness of artemether lumefantrine (ALu) in the Rufiji and Kilombero-Ulanga (KU) HDSS sites in rural Tanzania. Household and health facility surveys were conducted in low and high transmission seasons to determine access to an official ACT provider within 24h of fever onset, provider compliance, patient adherence and therapeutic efficacy. Access to an official ACT outlet was observed to be 37% in Rufiji and 42% in KU. Provider compliance was found to be 75% in Rufiji and 60% in KU. 65% of the patients from Rufiji and 71% of patients from KU adhered to treatment. This resulted in an overall systems effectiveness of 18% in Rufiji and 17% in KU. Health system factors contributing to this loss are suboptimal access and provider compliance. Well-designed system interventions are needed to strengthen the identified weaknesses in order to improve the effectiveness of ACTs as a malaria control strategy.

In India, iron deficiency anaemia remained an intractable problem despite national policies recommending routine iron-folate (IFA) and food supplementation. Poor effectiveness of IFA supplementation has been attributed to various factors including: Insufficient dose, Time of supplementation and Poor adherence. Understanding dose-response relationships between IFA and food supplementations during pregnancy with: severe/moderate and overall anameia in post-partum women and low birth weight (LBW) and neonatal mortality among infants - could help optimize implementation of anaemia control policies. We undertook an analysis of three large cross-sectional surveys in India during 2005-09, to test the hypothesis whether, ‘higher doses of IFA consumption during pregnancy improve post-partum haemoglobin (Hb), decrease severe/moderate and overall anaemia, decrease LBW, and decrease neonatal mortality or not. Our analysis showed, increase in IFA-dose during pregnancy resulted in corresponding increase in mean Hb level, significant drop in severe/moderate and overall anaemia, and significant drop in incidence of neonatal deaths, even after adjusting for socio-demographic factors. IFA supplementation increased the risk of LBW, although association was insignificant. Associations between exclusive food supplementation and outcomes were in expe

Background
Risk factors, early diagnosis and treatment for colorectal cancer (CRC) vary, and results in differences in incidence and outcomes across societies. To assess the influence of early diagnosis, we compare survival after CRC in a screened vs an unscreened population.

Methods
Relative survival (RS) analyses were performed to assess differences in outcomes for all CRC patients diagnosed in US SEER (2004, N=9349) and Norway (2004-05, N=8318). 39% died within three years.

Results
Stage distributions at diagnosis were different in US vs Norway (42% vs 22% localized; 35% vs 48% regional; 19% vs 23% distant). No (13%), minor (16%) or large (71%) resection rates were similar, but age and stage dependent. Overall 3-year RS was 72% in US and 67% in Norway. In multivariate models of age, sex, stage, and treatment, a weak country-effect was observed (excess mortality ratio (EMR) 0.9, CI 0.9-1.0), indicating better survival in the US, but this was significant for the youngest patients only (EMR 0.9, CI 0.8-0.9) for whom screening is an option.

Conclusion
The advantageous RS observed for US patients, and particularly for patients <80 years, likely reflects the earlier stage distribution, perhaps explained by different CRC screening practices as the US recommends screening whereas Norway does not.