Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan. Perceptions and utilization of primary health care services in Iraq: findings from a national household survey Eliciting public preference for health-care resource allocation in South Korea. An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women? Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention Institutional delivery in rural India: the relative importance of accessibility and economic status Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector. Improving private drug sellers' practices for managing common health problems in Nepal. 'The public is too subjective': public involvement at different levels of health-care decision making. Health insurance and health-seeking behavior: evidence from a randomized community-based insurance rollout in rural Burkina Faso. The Influence of “Stock out” on Health-Seeking Behavior of Low Income Women in Uyo Urban, Akwa Ibom State, Nigeria The impact of training informal health care providers in India: A randomized controlled trial Improving access to services and interactions with clients in Guatemala: the value of distance learning Economic Analysis of Health Care Technology: A Report on Principles Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India Effectiveness of Collaborative Care for Depression in Public-Sector Primary Care Clinics Serving Latinos. Assessing the Quality of Reproductive Health Services in Egypt via Exit Interviews
BACKGROUND Despite progress in improving health outcomes in Afghanistan by contracting public health services through non-governmental organizations ( NGOs ) , inequity in access persists between the poor and non-poor . This study examined the distributive effect of different contracting types on primary health services provision between the poor and non-poor in rural Afghanistan . METHOD Contracts to NGOs were made to deliver a common set of primary care services in each province , with the funding agencies determining contract terms . The contracting approaches could be classified into three contracting out types ( CO-1 , CO-2 and CO-3 ) and a contracting-in ( CI ) approach based on the contract terms , design and implementation . Exit interviews of patients attending r and omly sample d primary health facilities were collected through systematic sampling across 28 provinces at two time points . The outcome , the odds that a client attending a health facility is poor , was modelled using logistic regression with a robust variance estimator , and the effect of contracting was estimated using the difference-in-difference approach combined with stratified analyses . RESULTS The sample covered 5960 interviews from 306 health facilities in 2005 and 2008 . The adjusted odds of a poor client attending a health facility over time increased significantly for facilities under CO-1 and CO-2 , with odds ratio of 2.82 ( 1.49 , 5.36 ) P-value 0.001 and 2.00 ( 1.33 , 3.02 ) P-value 0.001 , respectively . The odds ratios for those under CO-3 and CI were not statistically significantly different over time . When compared with the non-contracting facilities , the adjusted ratio of odds ratios of poor status among clients was significantly higher for only those under CO-1 , ratio of 2.50 ( 1.32 , 4.74 ) P-value 0.005 . CONCLUSIONS CO-1 arrangement which allows contractors to decide on how funds are allocated within a fixed lump sum with non-negotiable deliverables , and actively managed through an independent government agency , is effective in improving equity of health services provision Background After many years of sanctions and conflict , Iraq is rebuilding its health system , with a strong emphasis on the traditional hospital-based services . A network exists of public sector hospitals and clinics , as well as private clinics and a few private hospitals . Little data are available about the approximately 1400 Primary Health Care clinics ( PHCCs ) staffed with doctors . How do Iraqis utilize primary health care services ? What are their preferences and perceptions of public primary health care clinics and private primary care services in general ? How does household wealth affect choice of services ? Methods A 1256 household national survey was conducted in the catchment areas of r and omly selected PHCCs in Iraq . A cluster of 10 households , beginning with a r and omly selected start household , were interviewed in the service areas of seven public sector PHCC facilities in each of 17 of Iraq 's 18 governorates . A question naire was developed using key informants . Teams of interviewers , including both males and females , were recruited and provided a week of training which included field practice . Teams then gathered data from households in the service areas of r and omly selected clinics . Results Iraqi participants are generally satisfied with the quality of primary care services available both in the public and private sector . Private clinics are generally the most popular source of primary care , however the PHCCs are utilized more by poorer households . In spite of free services available at PHCCs many households expressed difficulty in affording health care , especially in the purchase of medications . There is no evidence of informal payments to secure health services in the public sector . Conclusions There is widespread satisfaction reported with primary health care services , and levels did not differ appreciably between public and private sectors . The public sector PHCCs are preferentially used by poorer population s where they are important providers . PHCC services are indeed free , with little evidence of informal payments to providers OBJECTIVES To identify the principles the public considers important and the trade-offs between different values in health-care re source allocation practice s. METHODS This study approached the issue in both qualitative and quantitative ways . In a qualitative study , two focus groups discussed the issues of re source allocation in health care . To facilitate the discussion , a simple ranking task and a series of pairwise choice practice s were implemented . A discrete choice experiment survey question naire was also administered to a sample of the general population . Attributes and levels were determined through literature review s and the results from the focus group interview . We used a r and om-effect probit model to assess the effects of each attribute . RESULTS Through the focus group interviews , we found strong public support for the principle of equal opportunity . The participants thought that the severity of disease was the most important criterion when setting priorities . The majority supported the idea that the most disadvantaged should have the highest priority even when their health gains are less than those of others . The discrete choice experiment results showed that the severity of disease , health gains , and patients ' socioeconomic status significantly influence their choices , with each parameter having an expected sign . CONCLUSION The results showed that Koreans support not only health maximization but also equal opportunity , fair re source allocation , and e quality Maternal health services continue to favour the wealthiest in lower and middle income countries . Debate about the potential of performance-based financing ( PBF ) to address these disparities continues . As PBF is adopted by countries , it is critical to underst and the equity effects for maternal services . The aim of this study is to examine the effects of PBF on equity in maternal health service use when no specific provisions target the poorest in the population . In Rw and a , PBF was design ed to increase health service use , which was universally low . Paired districts were r and omly assigned to intervention and control for PBF implementation . Using Rw and a 's Demographic Health Survey data from 2005 ( pre-intervention ) and 2007 - 8 ( post-intervention ) , a cluster-level panel data set of 7899 women 15 - 49 years of age from intervention ( 4477 ) and control districts ( 3422 ) was created . The impact of PBF on reported use of facility deliveries , antenatal care ( ANC ) and modern contraceptive use was estimated using a difference-in-differences model with community fixed effects . Interaction terms between wealth quintiles and PBF were estimated to identify the differential effect of PBF among poorer women . The probability of a facility delivery increased by 10 percentage points in the intervention when compared with the control districts ( P = 0.014 ) , while no significant effects were noted for ANC visits or modern contraceptive use . Service use increased for intervention and control population s and across all wealth quintiles from 2005 to 2007 , with no evidence that PBF was a pro-poor or a pro-rich strategy . Insurance remained a positive predictor of service use . This research suggests that if service use is uniformly low then a PBF programme that incentivizes select services , such as facility deliveries , may improve service use overall . However , if the equity gap is extreme , then a PBF programme without equity targets will do little to alleviate disparities Background Dem and -side financing projects are now being implemented in many developing countries , yet evidence showing that they reach the poor is scanty . Methods A  maternal health voucher scheme provided voucher-paid services in Jhang , a predominantly rural district of Pakistan , during 2010 . A pre-test/post-test quasi-experimental design was used to assess the changes in the proportion of facility-based deliveries and related maternal health services among the poor . Household interviews were conducted with r and omly selected women in the intervention and control union councils , before and after the intervention . A strong outreach model was used . Voucher promoters were given basic training in identification of poor women using the Poverty Scorecard for Pakistan , in the types of problems women could face during delivery , and in the promotion of antenatal care ( ANC ) , institutional delivery and postnatal care ( PNC ) . Voucher booklets valued at Rs . 4,000 ( $ 48 ) , including three ANC visits , a PNC visit , an institutional delivery , and a postnatal family planning visit , were sold for Rs . 100 ( $ 1.2 ) to low-income women targeted by project outreach workers . Women suffering from complications were referred to emergency obstetric care services . Analysis was conducted at the bivariate and the multivariate levels . At the multivariate level , logistic regression analysis was conducted to determine whether the increase in institutional delivery was greater among poor women ( defined for this study as women in the fourth or fifth quintiles ) relative to non-poor women ( defined for this study as women in the first quintile ) in the intervention union councils compared to the control union councils . Results Bivariate analysis showed significant increases in the institutional delivery rate among women in the fourth or fifth wealth quintiles in the intervention union councils but no significant changes in this indicator among women in the same wealth quintiles in the control union councils . Multivariate analysis showed that the increase in institutional delivery among poor women relative to non-poor women was significantly greater in the intervention compared to the control union councils . Conclusions Dem and -side financing projects using vouchers can be an effective way of reducing inequities in institutional delivery Background Skilled attendance at delivery is an important indicator in monitoring progress towards Millennium Development Goal 5 to reduce the maternal mortality ratio by three quarters between 1990 and 2015 . In addition to professional attention , it is important that mothers deliver their babies in an appropriate setting , where life saving equipment and hygienic conditions can also help reduce the risk of complications that may cause death or illness to mother and child . Over the past decade interest has grown in examining influences on care-seeking behavior and this study investigates the determinants of place of delivery in rural India , with a particular focus on assessing the relative importance of community access and economic status . Methods A descriptive analysis of trends in place of delivery using data from two national representative sample surveys in 1992 and 1998 is followed by a two-level (  child/mother  and  community ) r and om-effects logistical regression model using the second survey to investigate the determinants . Results In this investigation of institutional care seeking for child birth in rural India , economic status emerges as a more crucial determinant than access . Economic status is also the strongest influence on the choice between a private-for-profit or public facility amongst institutional births . Conclusion Greater availability of obstetric services will not alone solve the problem of low institutional delivery rates . This is particularly true for the use of private-for-profit institutions , in which the distance to services does not have a significant adjusted effect . In the light of these findings a focus on increasing dem and for existing services seems the most rational action . In particular , financial constraints need to be addressed , and results support current trials of dem and side financing in India BACKGROUND Early detection and effective case management of tuberculosis ( TB ) among a high-risk group of material ly poor farm workers in an area of the Cape Winel and s , South Africa , presents special challenges to the health community , where re source constraints lead to service reduction . In order to address this problem , local nurses established a collaborative partnership between permanent farm workers and their families , their employers , selected non-governmental organizations and the public health sector . In consultation with stakeholders , they developed an intervention primarily focusing on having peer selected trained lay health workers ( LHWs ) on farms , mentored and managed by nurses . PURPOSE To describe the complex process of implementation and evaluation of the LHW project , and provide a summary of a number of discrete studies evaluating the effectiveness , cost implication s , and the perceptions and experiences of key stakeholders of the intervention . METHODS Quantitative and qualitative research methods conducted within the context of a pragmatic unblinded community cluster r and omized control trial were used . Emphasis was placed on an iterative participatory interaction between the research ers and key stakeholders . RESULTS The intervention contributed to significantly better successful treatment completion rates among adult new smear-positive TB cases . The process implemented proved cost-effective and was pivotal in initiating a community-based social development programme . CONCLUSIONS The use of peer-selected LHWs within a wider programme of integrated care design ed to merge technical biomedical approaches to disease management with more holistic social development activities , appears essential to meet the complex health needs in conjunction with public health of the rural poor BACKGROUND In most Asian countries , 50 - 90 % of pharmaceutical sales are made in private drug outlets , by personnel with some training in drugs but not for the treatment of common health problems . The objective of the study was to determine effects of focused training for private drug sellers to improve practice s in treating acute respiratory infections and diarrhoea in children , and anaemia in pregnancy in Nepal . METHODS R and omized controlled , four way nested design study incorporating four interventions for drug retailers in both hill and terai districts . One group received mailed printed educational material s followed by mailed feedback ; a second received small group training followed by feedback ; a third received small group training only ; and a fourth , the control group , received no intervention . Surrogate customer method was used to assess practice s. Outcomes were measured using multivariate linear regression . RESULTS A significant increase in the asking of key history questions , recommendation ( prescribing by drug retailers ) of cotrimoxazole , and advice-giving for pneumonia ; a significant increase in ORS recommendation , and advice giving for diarrhoea including the avoidance of antidiarrhoeals ; and a significant increase in asking key history questions and recommending appropriate products in pregnancy cases . CONCLUSIONS Training intervention as well as training followed by practice feedback was effective in improving the management of common illnesses and pregnancy by private drug sellers There are a number of impulses towards public participation in health care decision making including instrumentalist , communitarian , educative and expressive impulses and the desire for increased accountability . There has , however , been little research looking systematic ally at the public 's preferences for being involved in particular types of rationing decisions , nor indeed , has there been a critical examination of the degree of involvement desired by the public . The research reported here uses findings from focus groups and in-depth interviews to explore these questions . Eight focus groups were conducted with a total of 57 informants , four amongst r and omly selected members of the public and four with informants from health and non-health related organisations . Nineteen interviews were conducted to allow the elaboration of focus group comments , to probe views more deeply and to pursue emerging themes . The findings show variations in the willingness of members of the public to be involved in health care decisions and consistency across the different forms of the public as represented by the focus groups with r and omly selected citizens and pre-existing organisations . There was a strong desire in all the groups for the public to be involved both at the system and programme levels , with much less willingness to be involved at the individual level . At the system and programme levels informants generally favoured consultation , without responsibility for decisions , but with the guarantee that their contribution would be heard and that decisions taken following consultation would be explained . At the patient level informants felt that the public should participate only by setting criteria for deciding between potential beneficiaries of treatment . The public has much to contribute , particularly at the system and programme levels , to supplement the inputs of health care professionals In 2004 , a community-based health insurance ( CBI ) scheme was introduced in Nouna district , Burkina Faso , with the primary objective of improving access to facility-based health services . In order to overcome self- selection issues in the analysis of the behavioral effects of insurance , we combine four waves of the Nouna Health District Household Survey into a panel data set , and use the r and omized timing of insurance rollout to estimate the causal effect of insurance coverage on health-seeking behavior . While we find a generally positive association between CBI affiliation and treatment seeking , we can not reject the null that the introduction of health insurance does not have any effect on treatment seeking in general , and utilization of facility-based professional care , in particular . Low levels of health care provider satisfaction , poor perceived quality of care by enrollees , and ambiguity in the coverage level of the CBI benefit package appear to have contributed to these weak results . Our findings imply that the basic notion of insurance mechanically increasing facility-based professional care is not necessarily true empirically , and likely contingent on a large number of context ual factors affecting health-seeking behavior within households and communities The “ Health for All Project ” ( HFAP ) policy in Nigeria was complemented by the National Drug Policy to ensure constant availability of high quality drugs and medical consumables at affordable prices to citizens in public hospitals . Apart from strengthening the utilization of health services , the project also sought to improve health care delivery for the poor who could not afford the high cost of drugs in private clinics and pharmaceutical stores . Employing a survey method with stratified and systematic r and om techniques , the study found failed expectations in the promises of HFAP policy among the 1250 low-income women in Uyo urban . In the face of “ stock out ” where most drugs , pharmaceuticals , and medical supplies are consistently not available for dispensing in public hospitals and health centers poor urban women resorted to alternative health care in prayer houses , herbal homes , patent medicine vendors , health workers homes , and traditional birth attendants . The study reported that stock out in government health facilities result ed in health hazards and the relapse of illnesses as a result of non-adherence to treatment regime and exposure to fake , expired , and adulterated drugs . A renewed commitment in health care delivery in Nigeria is called for if poor women are to be really empowered Delivering health care to mystery patients Many families in developing countries do not have access to medical doctors and instead receive health care from informal providers . Das et al. used “ mystery ” patients ( trained actors ) to test whether a 9-month training program  improved the quality of care delivered by informal providers in West Bengal ( see the Perspective by Powell-Jackson ) . The patients did not identify themselves to the providers and were not told which providers had participated in the training program . The results of this blinded assessment showed that medical doctors delivered better care than informal providers but that the training program closed much of the gap . Science , this issue p. 80 ; see also p. 34 Training helped informal providers deliver better care for angina , diarrhea , and asthma . [ Also see Perspective by Powell-Jackson ] INTRODUCTION In rural India , health care providers without formal medical training and self-declared “ doctors ” are sought for up to 75 % of primary care visits . The frequent use of such informal providers , despite legal prohibitions on their practice s , in part reflects the absence of trained medical professionals in rural locations . For example , in the majority of villages in the Indian states of Rajasthan , Madhya Pradesh , and West Bengal , informal providers are the only proximate source of health care . RATIONALE The status of informal providers in the complex Indian health system is the subject of a highly charged debate among policy-makers and the medical establishment . The official view of the establishment is that fully trained providers are the only legitimate source of health care , and training informal providers legitimizes an illegal activity and worsens population health outcomes . In contrast , given the lack of availability of trained providers and the fact that informal providers are tightly linked with the communities that they serve , others believe that training can serve as a stopgap measure to improve health care in t and em with better regulation and reform of the public health care system . However , despite the policy interest and important ramifications for the country , there is little evidence regarding the benefits ( or lack thereof ) of training informal providers . We report on the impact of a multitopic training program for informal providers in the Indian state of West Bengal that provided 72 sessions of training over 9 months . We used a r and omized controlled trial design , together with visits by unannounced st and ardized patients ( “ mystery clients ” ) , to measure the extent to which training could improve the clinical practice of informal providers over the range of conditions that they face . The conditions presented by st and ardized patients were blinded from program implementers . Therefore , we view the evaluation of this multitopic training program as a measure of impact on primary care in general . St and ardized patient data are accompanied by data from day-long clinical observations , providing a comprehensive picture of provider practice . Our study also benchmarks the impact of training against the performance of doctors in public primary health centers serving the same region . Lastly , it explores whether the training affected patient dem and for informal providers .  RESULTS Mean attendance at each training session was 56 % [ 95 % confidence interval ( CI ) : 51 , 62 % ] , with no contamination from the control group . Using st and ardized patient data , we find that providers allocated to the training group were 4.1 ( 1.7 , 6.5 ) percentage points , or 15.2 % , more likely to adhere to condition-specific checklists than those in the control group . The training increased rates of correct case management by 7.9 ( 0.4 , 15.5 ) percentage points , or 14.2 % , and patient caseload by 0.8 to 1.8 ( 0.13 , 3.57 ) patients per day , or 7.6 to 17.0 % . Data from clinical observations show similar patterns . Although correct case management among doctors in public clinics was 14.7 ( –0.1 , 30.4 ) percentage points , or 28.3 % , higher than among untrained informal providers , the training program reduced this gap by half for providers with mean attendance and reduced the gap almost entirely for providers who completed the full course . However , the training had no effect on the use of unnecessary medicines and antibiotics , although both training- and control-group informal providers prescribed 18.8 ( 7.7 , 28.9 ) percentage points , or 28.2 % , fewer unnecessary antibiotics than public-sector providers . CONCLUSION Training informal providers increased correct case management rates but did not reduce the use of unnecessary medicines or antibiotics . At the same time , training did not lead informal providers to violate rules with greater frequency or worsen their clinical practice , both of which are concerns that have been raised by representatives of the Indian Medical Association . Our findings thus suggest that multitopic medical training may offer an effective short-run strategy to improved health care provision and complement critical investments in the quality of public care . Informal health care providers are the backbone of India ’s primary health care system . In rural India , up to 75 % of primary care visits are to informal providers . We evaluated a training program for these informal providers by using a r and omized controlled design . In our sample of 200 villages in West Bengal , there are 30 informal providers for every public-sector doctor . Health care providers without formal medical qualifications provide more than 70 % of all primary care in rural India . Training these informal providers may be one way to improve the quality of care where few alternatives exist . We report on a r and omized controlled trial assessing a program that provided 72 sessions of training over 9 months to 152 informal providers ( out of 304 ) . Using st and ardized patients ( “ mystery clients ” ) , we assessed clinical practice for three different conditions to which both providers and trainers were blinded during the intervention , representative of the range of conditions that these providers normally diagnose and treat . Training increased correct case management by 7.9 percentage points ( 14.2 % ) but did not affect the use of unnecessary medicines and antibiotics . At a program cost of $ 175 per trainee , our results suggest that multitopic medical training offers an effective short-run strategy to improve health care Objective To develop and test a distance-learning programme to improve the quality and efficiency of family planning services in Guatemala . Methods The setting was rural family planning services in Guatemala . The study design was quasi-experimental with one intervention and one control group and with pre- and post-intervention measures . Two staff members from each of 20 r and omly selected health districts were trained as leaders of the training programme . In turn , the 40 trainers trained a total of 240 service providers , under the supervision of four health area facilitators . The results were compared with 20 r and omly selected control health districts . The intervention was a distance-learning programme including 40 in-class hours followed by 120 inservice practice hours spread over a 4-month period . Distinctively , the programme used a cascade approach to training , intensive supervision , and close monitoring and evaluation . Patient flow analysis was used to determine number of contacts , waiting times , and the interaction time between service providers and clients . Consultation observations were used to assess the quality and completeness of reproductive health information and services received by clients . Results The intervention showed a positive impact on reducing the number of contacts before the consultation and client waiting times . More complete services and better quality services were provided at intervention clinics . Some , but not all , of the study objectives were attained . The long-term impact of the intervention is as yet unknown . Conclusion Distance-learning programmes are an effective methodology for training health professionals in rural areas Preamble Although economic outcomes research is an evolving field in health services research , there are correct and incorrect ways to conduct and report on economic outcomes studies . Research practice s that help to minimize real or perceived bias will increase the quality and usefulness of such studies for those who sponsor , publish , and use them . Because of public concerns about the potential for bias in the design , analysis , and reporting of economic analyses of health care technology , we formed a task force to develop principles to enhance the credibility of these studies . The Task Force on Principles for Economic Analysis of Health Care Technology included participants from academia , the pharmaceutical industry , the public sector , and private research organizations . As health care re sources become increasingly constrained , the information used to make re source allocation decisions must be as reliable , valid , and free of bias as possible . Getting it right at the level at which economic results are produced will help to protect consumers and will advance the health of the public . Bias stems from two broad categories : lack of appropriate independence for research ers and lack of consensus about methods . We focused heavily on the first of these categories for two major reasons . First , few have yet considered the unique issues of research er independence in economic outcomes research [ 1 , 2 ] . Second , other investigators have begun to consider and define proper methods for economic outcomes work ( an area of considerable controversy ) [ 3 - 5 ] . We also looked closely at the requirements for the reporting of economic analyses , which are intended to ensure method ologic transparency and accountability . The Need for Voluntary Guidelines Widespread use of economic analysis as part of the development of pharmaceutical , biotechnologic , and medical devices is relatively new . To date , many economic analyses of health care have focused on pharmaceutical agents , and many such studies have been funded by pharmaceutical companies . Results of these economic outcomes studies are used by medical technology firms to support the pricing and marketing of new interventions and to influence national health care systems and third-party payers in their development of coverage and payment decisions . Managed care organizations , hospitals , and government-subsidized health care programs rely on economic analysis of medical technology to help make formulary purchasing and utilization decisions . Physicians may use the results of these analyses to help guide treatment and prescription decisions . Health care economic outcomes projects are sponsored and conducted by pharmaceutical , biotechnologic , and medical device companies ; government agencies ; nonprofit foundations ; academic investigators ; and private research and consulting firms . The st and ards and methods used to evaluate the safety and efficacy of pharmaceutical products in r and omized , controlled trials have evolved over 50 years of collaboration among research ers in private , public , and academic setting s. Compared with those established to ensure the safety and efficacy of clinical trials , the principles and methods for the conduct of economic studies of health care technology are far less developed . Problems of conduct , reporting , and bias exist in all types of research [ 6 - 14 ] . In response , codes of conduct , such as those developed by the American Federation for Clinical Research and the Institute of Medicine , have been developed for many scientific disciplines [ 15 - 24 ] . These are good models on which to base principles of conduct for economic outcomes analysis . Although many published principles apply to economic studies , others should be modified and new ones should be developed to guide the conduct and reporting of economic outcomes analyses . Economic outcomes research requires unique guidelines for the following reasons : 1 ) As a field , it continues to evolve and is often misunderstood by end users ; 2 ) peer review of it requires special expertise that often exceeds the capabilities of review ers and scientific journals ; 3 ) it often uses secondary data and requires that many assumptions be made [ for example , attribution of a dollar cost to a unit of re source use ] ; 4 ) it offers unique method ologic choices , such as which types of costs to include ( direct , indirect , intangible , induced ) , which perspective to apply ( that of society , payer , provider , patient ) , which design to adopt ( cost- identification , costbenefit , cost-effectiveness , costutility ) , from where to obtain costs [ indemnity data base , managed care or capitated data base , hospital cost systems , Medicare , Medicaid ] , and whether to collect re source consumption data prospect ively or retrospectively through various modeling techniques ; and 5 ) economic studies play an increasingly important role in health care decision making because of increasing financial constraints throughout the health care industry . The financial and medical implication s of decision making done on the basis of these studies , coupled with the lack of widely accepted guidelines about the conduct and reporting of economic analyses , undermine the credibility of this research . A major issue is that the primary source of funding for this research is often the primary financial beneficiary of positive study results . Unfortunately , even valid studies done under the best of circumstances may be suspect [ 25 - 29 ] . This has led at least one major journal to conclude that these analyses should be viewed much like editorials or review articles are viewed in terms of potential for conflicts of interest [ 30 ] . We developed the guidelines reported here after extensive consultation with experts from the public , private , and academic sectors . We recommend that research ers and sponsors adhere to these guidelines , and we suggest they state publicly within their manuscripts that they have done so . End users , including journal editors and readers , consumers , and social decision makers , may then feel more secure in accepting the results of the research , while recognizing that intensive critique of the research will always be necessary . Operations of the Task Force The Task Force on Principles for Economic Analysis of Health Care Technology was initiated and organized by faculty from the Leonard Davis Institute ( LDI ) Center for Health Policy of the University of Pennsylvania . However , because not all LDI faculty were involved , this paper does not represent an official LDI position statement . The Task Force was funded by a coalition of pharmaceutical companies ( Appendix A ) . Funding was also requested ( but not obtained ) from various government and private foundations . All funding was provided in the form of unrestricted research grants or gifts to the University of Pennsylvania . Guidelines derive their credibility in part from the composition of the panel that creates them and the process by which they are developed . C and i date s for participation in the Task Force from the private sector and the academic research community were identified by the frequency with which they were cited in the health economics literature , which was obtained using a MEDLINE search of literature related to economic analyses of medical technology published between 1983 and 1992 . Approximately 15 members attended each meeting . Minutes were distributed after each meeting and approved by all members present . Members from the sponsoring pharmaceutical companies and the academic organizers rotated so that they numbered three and one , respectively , at the table for each formal Task Force meeting . Several professional and governmental organizations , including the Institute of Medicine , the Agency for Health Care Policy and Research , the Food and Drug Administration ( FDA ) , the Health Care Financing Administration , the Centers for Disease Control and Prevention , and a managed care organization , were asked to suggest persons who might participate . In addition , other organizations with a stake in economic analyses were each asked to suggest a person who , because of his or her professional background , had extensive knowledge of or experience with economic analyses . An academic pharmacist , an academic research er , a private research er , an ethicist and patient advocate , and an attorney specializing in medical ethics rounded out the Task Force ( Appendix B ) . Two members withdrew from participation . A small audience consisting of industry sponsors , academic organizers , staff , and a few other interested parties were invited to each meeting and allowed to comment . Four formal meetings of the Task Force were held in Philadelphia during 1993 and 1994 , and the most substantial work was done by various subcommittees between these meetings . The three main subcommittees were titled Ethical Conduct , Responsibility and Control ( the findings of these two subcommittees were later merged into one report ) , and Reporting Requirements for Economic Evaluations ( Appendix C ) . The Task Force was assisted by a professional facilitator . Although Task Force members sought consensus wherever possible on the key issues , consensus was not forced and recommendations were issued only when substantial agreement existed among the members . Task Force members were not asked to formally represent any organization . Formal endorsement of the final document was not sought . Copies of this report will be distributed to all organizations that were asked to suggest a participant and to other parties who responded to announcements placed in The New Engl and Journal of Medicine , Scrip , and the Pink Sheet . The Task Force findings will also be reported at academic conferences , medical profession meetings , and appropriate trade conventions . Findings and Recommendations Valid approaches to economic analyses can be defined ; acceptable methods can be differentiated from unacceptable ones . Bias in economic research stems from two major sources : lack of appropriate independence for Background After the launch of Janani Suraksha Yojana , a conditional cash transfer scheme in India , the proportion of women giving birth in institutions has rapidly increased . However , there are important gaps in quality of childbirth services during institutional deliveries . The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan . This intervention titled “ Parijaat ” was design ed by Action Research & Training for Health , in partnership with the state government and United Nations Population Fund . Methods The intervention was carried out in 44 public health facilities in 10 districts of Rajasthan , India . These included district hospitals ( 9 ) , community health centres ( 32 ) and primary health centres ( 3 ) . The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment , feedback , training and action . The adherence to evidence based practice s before , during and after this intervention were measured using structured checklists and scoring sheets . Main outcome measures included changes in practice s during labour , delivery or immediate postpartum period . Results Use of several unnecessary or harmful practice s reduced significantly . Most importantly , proportion of facilities using routine augmentation of labour reduced ( p = 0 ) , episiotomy for primigravidas ( p = 0.0003 ) , fundal pressure ( p = 0.0003 ) , and routine suction of newborns ( 0 = 0.0005 ) . Among the beneficial practice s , use of oxytocin after delivery increased ( p = 0.0001 ) and the practice of listening foetal heart sounds during labour ( p = 0.0001 ) . Some practice s did not show any improvements , such as dorsal position for delivery , use of partograph , and h and -washing . Conclusions An intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practice s at health facilities OBJECTIVE Quality improvement interventions for depression care have been shown to be effective for improving quality of care and depression outcomes in setting s with primarily insured patients . The aim of this study was to determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients seen in public-sector clinics . METHODS A total of 400 depressed patients from three public-sector primary care clinics were enrolled in a r and omized controlled trial of a tailored collaborative care intervention versus enhanced usual care .  Social workers without previous mental health experience served as depression care specialists for the intervention patients ( N=196 ) . Depending on patient preference , they delivered a cognitive-behavioral therapy ( CBT ) intervention or facilitated antidepressant medication given by primary care providers or both . In enhanced usual care , patients ( N=204 ) received a pamphlet about depression , a letter for their primary care provider stating that they had a positive depression screen , and a list of local mental health re sources . Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks . RESULTS Compared with patients in the enhanced usual care group , patients in the intervention group had significantly improved depression , quality of life , and satisfaction outcomes ( p<.001 for all ) . Intervention patients also had significantly improved quality -of-care indicators , including the proportion of patients receiving either psychotherapy or antidepressant medication ( 77 % versus 21 % , p<.001 ) . CONCLUSIONS Collaborative care for depression can greatly improve care and outcomes in public-sector clinics . Social workers without prior mental health experience can effectively provide CBT and manage depression care Background : This study assesses the quality of reproductive health services using client satisfaction exit interviews among three groups of primary health care units run by the Ministry of Health and Population of Egypt . Each group applied a different model of intervention . The Ministry will use the results in assessing its reproductive health component in the health sector reform program , and benefits from the strengths of other models of intervention . Methods : The sample was selected in two stages . First , a stratified r and om sampling procedure was used to select the health units . Then the sample of female clients in each health unit was selected using the systematic r and om approach , whereby one in every two women visiting the unit was approached . All women in the sample coming for reproductive health services were included in the analysis . Results : The results showed that reproductive health beneficiaries at the units implementing the new health sector reform program were more satisfied with the quality of services . Still there were various areas where clients showed significant dissatisfaction , such as waiting time , interior furnishings , cleanliness of the units and consultation time . The study showed that the staff of these units did not provide a conductive social environment as other interventions did . A significant proportion of women expressed their intention to go to private physicians owing to their flexible working hours and variety specializations . Conclusion : Beneficiaries were generally more satisfied with the quality of health services after attending the reformed units than the other types of units , but the generalization did not fully apply . Areas of weakness are identified
It was , however , evident that many interventions have worked successfully in poor communities and positive equity impacts can be inferred from interventions that work with types of providers predominantly used by poor people .
Background There has been a growing interest in the role of the private for-profit sector in health service provision in low- and middle-income countries .
The private sector represents an important source of care for all socioeconomic groups , including the poorest and substantial concerns have been raised about the quality of care it provides .
Interventions have been developed to address these technical failures and simultaneously take advantage of the potential for involving private providers to achieve public health goals .
Limited information is available on the extent to which these interventions have successfully exp and ed access to quality health services for poor and disadvantaged population s. This paper addresses this knowledge gap by presenting the results of a systematic literature review on the effectiveness of working with private for-profit providers to reach the poor .