Health Policy and Planning
Volume 30 Issue 10 December 2015
http://heapol.oxfordjournals.org/content/current

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Assessing the pro-poor effect of different contracting schemes for health services on health facilities in rural Afghanistan
Olakunle Alonge1,*, Shivam Gupta1, Cyrus Engineer1, Ahmad Shah Salehi2 and David H Peters1
Author Affiliations
1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Suite E8622, 615 N Wolfe Street, Baltimore, MD 21205, USA and
2Department of Health Economics and Finance, Afghanistan Ministry of Public Health, Kabul, Afghanistan
Accepted October 30, 2014.
Abstract
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 randomly sampled 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.

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Use of health care among febrile children from urban poor households in Senegal: does the neighbourhood have an impact?
Georges Karna Kone1,*, Richard Lalou2, Martine Audibert3, Hervé Lafarge4, Stéphanie Dos Santos2, Alphousseyni Ndonky2 and Jean-Yves Le Hesran5
Author Affiliations
1Centre de Recherche du Centre Hospitalier de l’Université de Montréal (CR CHUM) et Université de Daloa (Cote d’ivoire), 850 rue saint Denis Montréal, Canada,
2UMR 151 IRD/AMU, Laboratoire Population–Environnement–Développement, Aix-Marseille Université, centre Saint-Charles, Case 10, 3, place Victor-Hugo, 13331 Marseille cedex 3, France,
3CERDI, CNRS, 65 Boulevard François Mitterrand, 63000 Clermont-Ferrand, France,
4University of Paris Dauphine 32, avenue Henri Varagnat 93143 Bondy cedex, France
Accepted December 31, 2014.
Abstract
Urban malaria is considered a major public health problem in Africa. The malaria vector is well adapted in urban settings and autochthonous malaria has increased. Antimalarial treatments prescribed presumptively or after rapid diagnostic tests are also highly used in urban settings. Furthermore, health care strategies for urban malaria must comply with heterogeneous neighbourhood ecosystems where health-related risks and opportunities are spatially varied. This article aims to assess the capacity of the urban living environment to mitigate or increase individual or household vulnerabilities that influence the use of health services. The data are drawn from a survey on urban malaria conducted between 2008 and 2009. The study sample was selected using a two-stage randomized sampling. The questionnaire survey covered 2952 households that reported a case of fever episode in children below 10 years during the month before the survey.
Self-medication is a widespread practice for children, particularly among the poorest households in Dakar. For rich households, self-medication for children is more a transitional practice enabling families to avoid opportunity costs related to visits to health facilities. For the poorest, it is a forced choice and often the only treatment option. However, the poor that live in well-equipped neighbourhoods inhabited by wealthy residents tend to behave as their rich neighbours. They grasp the opportunities provided by the area and adjust their behaviours accordingly. Though health care for children is strongly influenced by household socio-economic characteristics, neighbourhood resources (facilities and social networks) will promote health care among the poorest and reduce access inequalities. Without being a key factor, the neighbourhood of residence—when it provides resources—may be of some help to overcome the financial hurdle. Findings suggest that the neighbourhood (local setting) is a relevant scale for health programmes in African cities.

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Perceptions of usage and unintended consequences of provision of ready-to-use therapeutic food for management of severe acute child malnutrition. A qualitative study in Southern Ethiopia
Elazar Tadesse1,2, Yemane Berhane2, Anders Hjern3, Pia Olsson1 and Eva-Charlotte Ekström1,*
Author Affiliations
1Department Women’s and Children’s Health, International Maternal and Child Health Uppsala University, SE-75185 Uppsala, Sweden,
2Department of Reproductive Health, Population and Nutrition, Addis Continental Institute of Public Health, Addis Ababa, Ethiopia and
3Clinical Epidemiology, Department of Medicine, Karolinska Institutet and Centre for Health Equity Studies, Stockholm, Sweden
Accepted January 16, 2015.
Abstract
Background: Severe acute child malnutrition (SAM) is associated with high risk of mortality. To increase programme effectiveness in management of SAM, community-based management of acute malnutrition (CMAM) programme that treats SAM using ready-to-use-therapeutic foods (RUTF) has been scaled-up and integrated into existing government health systems. The study aimed to examine caregivers’ and health workers perceptions of usages of RUTF in a chronically food insecure area in South Ethiopia.
Methods: This qualitative study recorded, transcribed and translated focus group discussions and individual interviews with caregivers of SAM children and community health workers (CHWs). Data were complemented with field notes before qualitative content analysis was applied.
Results: RUTF was perceived and used as an effective treatment of SAM; however, caregivers also see it as food to be shared and when necessary a commodity to be sold for collective benefits for the household. Caregivers expected prolonged provision of RUTF to contribute to household resources, while the programme guidelines prescribed RUTF as a short-term treatment to an acute condition in a child. To get prolonged access to RUTF caregivers altered the identities of SAM children and sought multiple admissions to CMAM programme at different health posts that lead to various control measures by the CHWs.
Conclusion: Even though health workers provide RUTF as a treatment for SAM children, their caregivers use it also for meeting broader food and economic needs of the household endangering the effectiveness of CMAM programme. In chronically food insecure contexts, interventions that also address economic and food needs of entire household are essential to ensure successful treatment of SAM children. This may need a shift to view SAM as a symptom of broader problems affecting a family rather than a disease in an individual child.

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Breast cancer in the global south and the limitations of a biomedical framing: a critical review of the literature
Catia C. Confortini* and Brianna Krong
Author Affiliations
Peace and Justice Studies Program, Wellesley College, 106 Central Street, Wellesley, MA 02481, USA
Accepted November 21, 2014.
Abstract
Public health researchers are devoting increasing attention to the growing burden of breast cancer in low-and middle-income countries (LMICs), previously thought to be minimally impacted by this disease. A critical examination of this body of literature is needed to explore the assumptions, advantages and limitations of current approaches. In our critical literature review, we find that researchers and public health practitioners predominantly privilege a biomedical perspective focused on patients’ adherence (or non-adherence) to ‘preventive’ practices, screening behaviours and treatment regimens. Cost-effective ‘quick fixes’ are prioritized, and prevention is framed in terms of individual ‘risk behaviours’. Thus, individuals and communities are held responsible for the success of the biomedical system; traditional belief systems and ‘harmful’ social practices are problematized. Inherently personal, social and cultural experiences of pain and suffering are neglected or reduced to the issue of chemical palliation. This narrow approach obscures the complex aetiology of the disease and perpetuates silence around power relations. This article calls for a social justice-oriented interrogation of the role of power and inequity in the global breast cancer epidemic, which recognizes the agency and experiences of women (and men) who experience breast cancer in the global south.