Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries Unravelling the quality of HIV counselling and testing services in the private and public sectors in Zambia Perceptions and utilization of primary health care services in Iraq: findings from a national household survey Study protocol for a cluster-randomised controlled trial of an NCD access to medicines initiative: evaluation of Novartis Access in Kenya Partner Management for Gonococcal and Chlamydial Infection: Expansion of Public Health Services to the Private Sector and Expedited Sex Partner Treatment Through a Partnership With Commercial Pharmacies Institutional delivery in rural India: the relative importance of accessibility and economic status Quality of generic medicines in South Africa: Perceptions versus Reality – A qualitative study Economic Analysis of Health Care Technology: A Report on Principles A combined community- and facility-based approach to improve pregnancy outcomes in low-resource settings: a Global Network cluster randomized trial Can computers improve patient care by primary health care workers in India? Anti-diabetic drugs in the private and public sector in Dar es Salaam, Tanzania. Tackling inequalities in obesity: a protocol for a systematic review of the effectiveness of public health interventions at reducing socioeconomic inequalities in obesity amongst children Health care providers' attitudes towards termination of pregnancy: A qualitative study in South Africa The impact of a lay counselor led collaborative care intervention for common mental disorders in public and private primary care: A qualitative evaluation nested in the MANAS trial in Goa, India☆ Improving mental health among people living with HIV: a review of intervention trials in low- and middle-income countries Is the public healthcare sector a more strenuous working environment than the private sector for a physician? Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities An equity analysis of performance-based financing in Rwanda: are services reaching the poorest women? Telemedicine for the Medicare population: pediatric, obstetric, and clinician-indirect home interventions. The impact of population-based disease management services for selected chronic conditions: the Costs to Australian Private Insurance - Coaching Health (CAPICHe) study protocol A clinical training unit for diarrhoea and acute respiratory infections: an intervention for primary health care physicians in Mexico. Panic disorder in public sector primary care: clinical characteristics and illness severity compared with "mainstream" primary care panic disorder. Introducing rapid diagnostic tests for malaria into registered drug shops in Uganda: lessons learned and policy implications
Background Artemisinin-based combination therapy ( ACT ) is the first-line malaria treatment throughout most of the malaria-endemic world . Data on ACT availability , price and market share are needed to provide a firm evidence base from which to assess the current situation concerning quality -assured ACT supply . This paper presents supply side data from ACTwatch outlet surveys in Benin , the Democratic Republic of Congo ( DRC ) , Madagascar , Nigeria , Ug and a and Zambia . Methods Between March 2009 and June 2010 , nationally representative surveys of outlets providing anti-malarials to consumers were conducted . A census of all outlets with the potential to provide anti-malarials was conducted in clusters sample d r and omly . Results 28,263 outlets were censused , 51,158 anti-malarials were audited , and 9,118 providers interviewed . The proportion of public health facilities with at least one first-line quality -assured ACT in stock ranged between 43 % and 85 % . Among private sector outlets stocking at least one anti-malarial , non-artemisinin therapies , such as chloroquine and sulphadoxine-pyrimethamine , were widely available ( > 95 % of outlets ) as compared to first-line quality -assured ACT ( < 25 % ) . In the public/not-for-profit sector , first-line quality -assured ACT was available for free in all countries except Benin and the DRC ( US$ 1.29 [ Inter Quartile Range ( IQR ) : $ 1.29-$1.29 ] and $ 0.52[IQR : $ 0.00-$1.29 ] per adult equivalent dose respectively ) . In the private sector , first-line quality -assured ACT was 5 - 24 times more expensive than non-artemisinin therapies . The exception was Madagascar where , due to national social marketing of subsidized ACT , the price of first-line quality -assured ACT  ( $ 0.14 [ IQR : $ 0.10 , $ 0.57 ] ) was significantly lower than the most popular treatment ( chloroquine , $ 0.36 [ IQR : $ 0.36 , $ 0.36 ] ) .  Quality -assured ACT accounted for less than 25 % of total anti-malarial volumes ; private-sector quality -assured ACT volumes represented less than 6 % of the total market share . Most anti-malarials were distributed through the private sector , but often comprised non-artemisinin therapies , and in the DRC and Nigeria , oral artemisinin monotherapies .  Provider knowledge of the first-line treatment was significantly lower in the private sector than in the public/not-for-profit sector . Conclusions These st and ardized , nationally representative results demonstrate the typically low availability , low market share and high prices of ACT , in the private sector where most anti-malarials are accessed , with some exceptions . The results confirm that there is substantial room to improve availability and affordability of ACT treatment in the surveyed countries . The data will also be useful for monitoring the impact of interventions such as the Affordable Medicines Facility for malaria Background Despite the substantial investment for providing  HIV counselling and testing ( VCT ) services in Zambia , there has been little effort to systematic ally evaluate the quality of  VCT services provided by various types of health providers . This study , conducted in 2009 , examines  VCT in the public and private sectors including private for-profit and NGO/faith-based sectors in Copperbelt and Luapula . Methods The study used five primary data collection methods to gauge quality of  VCT services  : closed-ended client interviews with clients exiting  VCT sites ; open-ended client interviews ; interviews with facility managers ; review of service statistics ; and an observation of the physical environment for VCT by site .  Over 400 clients and 87 facility managers were interviewed from almost 90 facilities . Sites were r and omly selected and results are generalizable at the provincial level . Results The study shows concerning levels of underperformance in VCT services  across the sectors . It reveals serious underperformance in counselling about key risk-reduction methods . Less than one-third of clients received counselling on reducing number of sexual partners and only approximately 5 % of clients received counselling about disclosing test results to partners . In terms of client profiles , the NGO sector attracts the most educated clients and less educated Zambians seek  VCT  services at very low rates ( 7 % ) . The private for-profit performs equally or sometimes better than other sectors even though this sector is not adequately integrated into the Zambian national response to HIV . Conclusion The private for-profit sector provides  VCT services  on par in quality with the other sectors . Most clients did not receive counselling on partner reduction or disclosure of HIV test results to partners . In a generalized HIV epidemic where multiple concurrent sexual partners are a significant problem for transmitting the disease , risk-reduction methods and discussion should be a main focus of pre-test and post-test counselling 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 Introduction Novartis recently launched Novartis Access , an initiative to provide a basket of reduced price medicines for non-communicable diseases ( NCDs ) to be sold through the public and private non-profit sectors in programme countries . This study will evaluate the impact of Novartis Access on the availability and price of NCD medicines at health facilities and households in Kenya , the first country to receive the programme . Methods and analysis This study will be a cluster-r and omised controlled trial . 8 counties in Kenya will be r and omly assigned to the intervention or control group using a covariate constrained r and omisation method to maximise balance on demographic and health characteristics . In intervention counties , public and private non-profit health facilities will be able to order Novartis Access NCD medicines from the Mission for Essential Drugs and Supplies ( MEDS ) . Data will be collected from a r and om sample of 384 health facilities and 800 households at baseline , midline after 1-year of intervention , and end-line after 2 years . Quarterly surveillance data will also be collected from health facilities and a sub sample of households through phone-based interviews . Households will be eligible if at least one resident has been previously diagnosed and prescribed a medicine for an NCD addressed by Novartis Access , including hypertension and diabetes . The primary outcomes will be availability and price of NCD medicines at health facilities , and availability , price , and expenditures on NCD medicines at households . Impacts will be estimated using intention-to-treat analysis . Ethics and dissemination This protocol was approved by the Institutional Review Boards at Strathmore University and at Boston University . Informed consent will be obtained from all participants at the start of the trial . The findings of the trial will be disseminated through peer- review ed journals , international conferences , and meetings and events organised with local stakeholders . Trial registration number NCT02773095 Background Public health partner notification ( PN ) services currently affect only a small minority of patients with gonorrhea or chlamydial infection and new approaches to PN are needed . Objectives To exp and PN for gonorrhea and chlamydial infection to private sector patients and to assess the feasibility of treating sex partners through commercial pharmacies . Methods Selected patients were offered PN assistance  and were r and omly offered medication to deliver to their partners . Results Providers permitted the health department to contact 3613 ( 91 % ) of 3972 potentially eligible patients , and 1693 ( 67 % ) of 2531 successfully contacted patients consented to interview . Of these , 1095 ( 65 % ) reported at least one untreated partner . Most patients ( 90 % ) wished to notify partners themselves . Patients were more likely to have partners who had not yet been treated and to request  PN assistance  if they had more than one sex partner in the preceding 60 days or a partner they did not anticipate having sex with in the future . These two factors characterized 49 % of all patients interviewed , 70 % of those with a partner that was untreated 7 or more days after index patient treatment , and 83 % of those accepting PN assistance . Among 458 r and omly selected patients with untreated partners at time of study interview , 346 ( 76 % ) agreed to deliver treatment to a partner . Of these , most ( 266 ) chose to obtain medication for a partner at a pharmacy , of whom 223 ( 84 % ) successfully did so . Conclusion A substantial minority of private sector patients have untreated partners more than 7 days after their own treatment ; some need help with PN , but most will agree to deliver medication to partners themselves 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 Generic Medicines are an important policy option allowing for access to affordable , essential medicines . Quality of generic medicines must be guaranteed through the activities of national medicines regulatory authorities . Existing negative perceptions surrounding the quality of generic medicines must be addressed to ensure that people use them with confidence . Campaigns to increase the uptake of generic medicines by consumers and providers of healthcare need to be informed by local norms and practice s. This study sought to compare South African consumers ’ and healthcare providers ’ perceptions of quality of generics to the actual quality of selected products . Methods The study was conducted at the local level in three cities of South Africa : Johannesburg , Durban and Cape Town . Purposive sampling was used to recruit consumer participants ( n = 73 ) and r and om sampling used to recruit healthcare providers from public and private sectors ( n = 15 ) . Data were obtained through twelve focus group discussion s with consumers and semi-structured interviews ( n = 15 ) with healthcare providers in order to gain familiarity with perceptions of quality . One hundred and thirty five products comprising paracetamol tablets ( n = 47 ) , amoxicillin capsules ( n = 45 ) and hydrochlorothiazide tablets ( n = 43 ) were source d from public and private sector healthcare providers . These products were subjected to in vitro dissolution , uniformity of weight and identity ( Fourier Transformed Infrared Spectroscopy ) tests using prescribed methods from the British ( 2005 ) and United States Pharmacopeias ( 2006 ) . Results Respondents described drug quality in relation to the effect on symptoms . Procurement and use behavior of healthcare providers was influenced by prior experience , manufacturers ’ names and consumers ’ ability to pay . All formulations passed the in vitro tests for quality . Conclusions This study showed clear differences between perceptions of quality and actual quality of medicines suggesting deficiencies in public engagement by government regarding the implementation of generic medicines policy . Implementation of generic medicines policy requires the involvement of consumers and healthcare providers to specifically address their information gaps and needs 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 Fetal and neonatal mortality rates in low-income countries are at least 10-fold greater than in high-income countries . These differences have been related to poor access to and poor quality of obstetric and neonatal care . Methods This trial tested the hypothesis that teams of health care providers , administrators and local residents can address the problem of limited access to quality obstetric and neonatal care and lead to a reduction in perinatal mortality in intervention compared to control locations . In seven geographic areas in five low-income and one middle-income country , most with high perinatal mortality rates and substantial numbers of home deliveries , we performed a cluster r and omized non-masked trial of a package of interventions that included community mobilization focusing on birth planning and hospital transport , community birth attendant training in problem recognition , and facility staff training in the management of obstetric and neonatal emergencies . The primary outcome was perinatal mortality at ≥28 weeks gestation or birth weight ≥1000 g. Results Despite extensive effort in all sites in each of the three intervention areas , no differences emerged in the primary or any secondary outcome between the intervention and control clusters . In both groups , the mean perinatal mortality was 40.1/1,000 births ( P = 0.9996 ) . Neither were there differences between the two groups in outcomes in the last six months of the project , in the year following intervention cessation , nor in the clusters that best implemented the intervention . Conclusions This cluster r and omized comprehensive , large-scale , multi-sector intervention did not result in detectable impact on the proposed outcomes . While this does not negate the importance of these interventions , we expect that achieving improvement in pregnancy outcomes in these setting s will require substantially more obstetric and neonatal care infrastructure than was available at the sites during this trial , and without them provider training and community mobilization will not be sufficient . Our results highlight the critical importance of evaluating outcomes in r and omized trials , as interventions that should be effective may not be . Trial registration Clinical Trials.gov OBJECTIVE The objective was to test whether a decision support technology for non-physicians can increase health care utilization and quality . DESIGN Before and after measurements were taken from a systematic r and om sample of patients and staff at r and omly assigned intervention and control facilities . SETTING The study took place at primary health facilities in rural Tamil Nadu , India . PARTICIPANTS One thous and two hundred and eighty-six patients and 82 staff were interviewed . INTERVENTION A computer-assisted decision support technology was introduced to assist with patient screening . MAIN OUTCOME MEASURES Outcome measures included new patient visits per month , a Global Patient Assessment of Care Index , and health worker attitude variables . RESULTS There was a difference of difference of 430 new patient visits per month at the intervention sites ( P = 0.005 ) , an increase from baseline of 18 % at intervention sites compared with a decline of 5 % at control sites . The intervention was associated with significant improvements in a Global Patient Assessment of Care Index ( mean difference of difference 7.9 , P < 0.001 ) . The largest gains were made in patient communication , technical quality , and general satisfaction with care . The attitudes of public health workers toward the new technology and their jobs did not change . CONCLUSIONS Decision support technologies have considerable potential to improve coverage and quality of health care for the poor and where there is no doctor , but the unreceptive attitude of public health workers would need to be overcome . Application of these technologies should take advantage of their popularity with patients and the opportunity to work through the private sector OBJECTIVES To compare availability , cost , affordability and sources of anti-diabetic drugs  between private and public health facilities in Dar es Salaam , Tanzania . DESIGN Cross sectional descriptive study . SETTING Diabetic clinics in private and public health facilities in Dar es Salaam , Tanzania . SUBJECTS Eighty patients r and omly selected and 45 health facility personnel staff working in the diabetic clinics .  Semi-structured question naires and a checklist were used to collect the information . RESULTS Oral hypoglycaemic agents were available in all seven private and three public facilities that were studied . Private facilities stocked more types of oral hypoglycaemic agents than public facilities , which stocked only chlorpropamide and tolbutamide , based on the National Essential Drugs List . The cost of chlorpropamide  was five times higher in private facilities compared to public facilities .  Insulin  was also available in all the facilities . The price of animal insulin  in private health facilities was ten times that in public health facilities .  Human insulin  , which is generally more expensive than animal insulin , was only available in private facilities . Although prices were much lower in public facilities , affordability emerged as a common issue in both private and public facilities . CONCLUSIONS Urban private health facilities offer a wider choice for the needs of diabetic patients but this advantage is compromised by higher prices as compared to public facilities as well as inconsistent supply across facilities . Public health facilities offer only a limited selection of essential oral hypoglycaemics and insulin but at a lower price and across all facilities . Twenty six per cent and 10 % of patients in public and private facilities respectively are unable to afford anti-diabetic drugs . The need for intervention to increase affordability of anti-diabetic drugs is evident . Financing and cost of drugs needs to be addressed , either by means of health insurance or other mechanisms , in this era of increasing prevalence of diabetes mellitus among developing countries Background There is growing evidence of the impact of overweight and obesity on short- and long-term functioning , health and well-being . Internationally , childhood obesity rates continue to rise in some countries ( for example , Mexico , India , China and Canada ) , although there is emerging evidence of a slowing of this increase or a plateauing in some age groups . In most European countries , the United States and Australia , however , socioeconomic inequalities in relation to obesity and risk factors for obesity are widening . Addressing inequalities in obesity , therefore , has a very high profile on the public health and health services agendas . However , there is a lack of accessible policy-ready evidence on what works in terms of interventions to reduce inequalities in obesity . Methods and design This article describes the protocol for a National Health Service Trust ( NHS ) National Institute for Health Research -funded systematic review of public health interventions at the individual , community and societal levels which might reduce socioeconomic inequalities in relation to obesity amongst children ages 0 to 18 years . The studies will be selected only if ( 1 ) they included a primary outcome that is a proxy for body fatness and ( 2 ) examined differential effects with regard to socioeconomic status ( education , income , occupation , social class , deprivation and poverty ) or the intervention was targeted specifically at disadvantaged groups ( for example , children of the unemployed , lone parents , low income and so on ) or at people who live in deprived areas . A rigorous and inclusive international literature search will be conducted for r and omised and nonr and omised controlled trials , prospect i ve and retrospective cohort studies ( with and /or without control groups ) and prospect i ve repeat cross-sectional studies ( with and /or without control groups ) . The following electronic data bases will be search ed : MEDLINE , Embase , CINAHL , PsycINFO , Social Science Citation Index , ASSIA , IBSS , Sociological Abstract s and the NHS Economic Evaluation Data base . Data base search es will be supplemented with website and grey literature search es . No studies will be excluded on the basis of language , country of origin or publication date . Study inclusion , data extraction and quality appraisal will be conducted by two review ers . Meta- analysis and narrative synthesis will be conducted . The main analysis will examine the effects of ( 1 ) individual , ( 2 ) community and ( 3 ) societal level public health interventions on socioeconomic inequalities in childhood obesity . Interventions will be characterised by their level of action and their approach to tackling inequalities . Context ual information on how such public health interventions are organised , implemented and delivered will also be examined . Discussion In this review , we consider public health strategies which reduce and prevent inequalities in the prevalence of childhood obesity , highlight any gaps in the evidence base and seek to establish how such public health interventions are organised , implemented and delivered . PROSPERO registration number : Background Despite changes to the abortion legislation in South Africa in 1996 , barriers to women accessing abortion services still exist including provider opposition to abortions and a shortage of trained and willing abortion care providers . The dearth of abortion providers undermines the availability of safe , legal abortion , and has serious implication s for women 's access to abortion services and health service planning . In South Africa , little is known about the personal and professional attitudes of individuals who are currently working in abortion service provision . Exploring the factors which determine health care providers ' involvement or disengagement in abortion services may facilitate improvement in the planning and provision of future services . Methods Qualitative research methods were used to collect data . Thirty four in-depth interviews  and one focus group discussion were conducted during 2006 and 2007 with health care providers who were involved in a range of abortion provision in the Western Cape Province , South Africa . Data were analysed using a thematic analysis approach . Results Complex patterns of service delivery were prevalent throughout many of the health care facilities , and fragmented levels of service provision operated in order to accommo date health care providers ' willingness to be involved in different aspects of abortion provision . Related to this was the need expressed by many providers for dedicated , st and -alone abortion clinics thereby creating a more supportive environment for both clients and providers . Almost all providers were concerned about the numerous difficulties women faced in seeking an abortion and their general quality of care . An overriding concern was poor pre and post abortion counselling including contraceptive counselling and provision . Conclusion This is the first known qualitative study undertaken in South Africa exploring providers ' attitudes towards abortion and adds to the body of information addressing the barriers to safe abortion services . In order to sustain a pool of abortion providers , programmes which both attract prospect i ve abortion providers , and retain existing providers , needs to be developed and financial compensation for abortion care providers needs to be considered The MANAS trial evaluated the effectiveness of a lay counselor led collaborative stepped care intervention for Common Mental Disorders ( CMD ) in public and private sector primary care setting s in Goa , India . This paper describes the qualitative findings of the experience of the intervention and its impact on health and psychosocial outcomes .  Twenty four primary care facilities ( 12 public and private each ) were r and omized to provide either collaborative stepped care ( CSC ) or enhanced usual care ( EUC ) to adults who screen positive for CMDs . Participants were sample d purposively based on two criteria : gender and , in the CSC arm , adherence with the intervention . The qualitative study component involved two semi-structured interviews with participants of both arms ( N = 115 ) ; the first interview within 2 months of recruitment and the second 6–8 months after recruitment . Data were collected between September 2007 and November 2009 . More participants in the CSC than EUC arm reported relief from symptoms and an improvement in social functioning and positive impact on work and activities of daily life . The CSC participants attributed their improvement both to medication received from the doctors and the strategies suggested by the lay Health Counselors ( HC ) . However , two key differences were observed in the results for the two types of facilities . First , the CSC participants in the public sector clinics were more likely to consider the HCs to be an important component of providing care who served as a link between patient and the doctor , provided them skills on stress management and helped in adherence to medication . Second , in the private sector , doctors performed roles similar to those of the HCs and participants in both arms placed much faith in the doctor who acted as a confidante and was perceived to underst and the participant 's health and context intimately . Lay counselors working in a CSC model have a positive effect on symptomatic relief , social functioning and satisfaction with care in patients with CMD attending primary care clinics although the impact , compared with usual care , is greater in the public sector People living with HIV ( PLWH ) experience greater psychological distress than the general population . Evidence from high-incomes countries suggests that psychological interventions for PLWH can improve mental health symptoms , quality of life , and HIV care engagement . However , little is known about the effectiveness of mental health interventions for PLWH in low- and middle-income countries ( LMICs ) , where the large majority of PLWH reside . This systematized review aims to synthesize findings from mental health intervention trials with PLWH in LMICs to inform the delivery of mental health services in these setting s. A systematic search strategy was undertaken to identify peer- review ed published papers of intervention trials addressing negative psychological states or disorders ( e.g. depression , anxiety ) among PLWH in LMIC setting s. Search results were assessed against pre-established inclusion and exclusion criteria . Data from papers meeting criteria were extracted for synthesis . Twenty-six papers , published between 2000 and 2014 , describing 22 unique interventions were identified . Trials were implemented in sub-Saharan Africa ( n = 13 ) , Asia ( n = 7 ) , and the Middle East ( n = 2 ) , and addressed mental health using a variety of approaches , including cognitive-behavioral ( n = 18 ) , family-level ( n = 2 ) , and pharmacological ( n = 2 ) treatments . Four r and omized controlled trials reported significant intervention effects in mental health outcomes , and 11 preliminary studies demonstrated promising findings . Among the limited mental health intervention trials with PLWH in LMICs , few demonstrated efficacy .  Mental health interventions for PLWH in LMICs must be further developed and adapted for re source -limited setting s to improve effectiveness Aims : The present study examined the differences between physicians working in public and private health care in strenuous working environments ( presence of occupational hazards , physical violence , and presenteeism ) and health behaviours ( alcohol consumption , body mass index , and physical activity ) . In addition , we examined whether gender or age moderated these potential differences . Methods : Cross-sectional survey data were compiled on 1422 female and 948 male r and omly selected physicians aged 25–65 years from The Finnish Health Care Professionals Study .  Logistic regression and linear regression analyses were used with adjustment for gender , age , specialisation status , working time , managerial position , and on-call duty . Results : Occupational hazards , physical violence , and presenteeism were more commonly reported by physicians working in the public sector than by their counterparts in the private sector . Among physicians aged 50 years or younger , those who worked in the public sector consumed more alcohol than those who worked in the private sector , whereas in those aged 50 or more the reverse was true . In addition , working in the private sector was most strongly associated with lower levels of physical violence in those who were older than 50 years , and with lower levels of presenteeism among those aged 40–50 years . Conclusions : The present study found evidence for the public sector being a more strenuous work environment for physicians than the private sector . Our results suggest that public healthcare organisations should pay more attention to the working conditions of their employees ABSTRACT BACKGROUND Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care . Quality improvement ( QI ) programs for depression in primary care improve outcomes relative to usual care , but health , social and other community-based service sectors also support clients in under-re source d communities . Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors . OBJECTIVE To compare the effectiveness of Community Engagement and Planning ( CEP ) and Re sources for Services ( RS ) to implement depression QI on clients ’ mental health-related quality of life ( HRQL ) and services use . DESIGN Matched programs from health , social and other service sectors were r and omized to community engagement and planning ( promoting inter-agency collaboration ) or re sources for services ( individual program technical assistance plus outreach ) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles . PARTICIPANTS From 93 r and omized programs , 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Question naire ( PHQ-8 ) and providing contact information , 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up . MEASURES Self-reported mental HRQL and probable depression ( primary ) , physical activity , employment , homelessness risk factors ( secondary ) and services use . RESULTS CEP was more effective than RS at improving mental HRQL , increasing physical activity and reducing homelessness risk factors , rate of behavioral health hospitalization and medication visits among specialty care users ( i.e. psychiatrists , mental health providers ) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs ( each p < 0.05 ) . Employment , use of antidepressants , and total contacts were not significantly affected ( each p > 0.05 ) . CONCLUSION Community engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than re sources for services for individual programs in improving mental HRQL , physical activity and homelessness risk factors , and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors , offering an exp and ed health-home model to address multiple disparities for depressed safety-net clients 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 This report is a supplement to an earlier evidence report ,  Telemedicine for the Medicare Population , which was intended to help policymakers weigh the evidence relevant to coverage of telemedicine services under Medicare . That report focused on telemedicine programs and clinical setting s that had been used with or were likely to be applied to Medicare beneficiaries . While we prepared that report , it became apparent that there are also telemedicine studies among non-Medicare beneficiaries -- e.g . , children and pregnant women -- that could inform policymakers and provide more comprehensive evidence of the state of the science regarding telemedicine applications . In addition , the first evidence report only partially included a class of telemedicine applications ( called self-monitoring/testing telemedicine ) in which the beneficiary used a home computer  or modern-driven telephone system  to either report information or access information and support from Internet re sources and indirectly interact with a clinician . Self-monitoring/testing applications in the first report required direct interaction with a clinician . The goal of this report is to systematic ally review the evidence in the clinical areas of pediatric and obstetric telemedicine as well as home-based telemedicine where there is indirect involvement of the health care professional . ( In this report , we will refer to the latter as clinician-indirect home telemedicine . ) Specifically , the report summarizes scientific evidence on the diagnostic accuracy , access , clinical outcomes , satisfaction , and cost-effectiveness of services provided by telemedicine technologies for these patient groups . It also identifies gaps in the evidence and makes recommendations for evaluating telemedicine services for these population s in the future . The evidence is clustered according to three categories of telemedicine service defined in our original report : store- and -forward , self-monitoring/testing , and clinician-interactive services . The three clinical practice areas review ed in this report are defined as follows . The term pediatric applies to any telemedicine study in which the sample consisted wholly or partially of persons aged 18 or younger , including studies with neonatal sample s. The term obstetric applies to any telemedicine study in which the sample consisted entirely of women seeking pregnancy-related care . The term clinician-indirect home telemedicine applies to home-based telemedicine ( called self-monitoring/testing in our original report ) where a telemedicine application used in the home has only indirect involvement by the health care professional . Interactive home telemedicine was applied in this report to all patient population s. KEY QUESTIONS The key questions that served as a guide for review ing the literature in the evaluation of pediatric , obstetric , and clinician-indirect  home telemedicine applications were derived by consensus among the evidence - review team based on the analytic framework established for the original evidence report . For the current report , the questions were applied to studies in all three practice areas as a whole group within each of the three categories of telemedicine services : store- and -forward ; self-monitoring/testing ; and clinician-interactive . The specific key questions were : 1 . Does telemedicine result in comparable diagnosis and appropriateness of recommendations for management ? 2 . Does the availability of telemedicine provide comparable access to care ? 3 . Does telemedicine result in comparable health outcomes ? 4 . Does telemedicine result in comparable patient or clinician satisfaction with care ? 5 . Does telemedicine result in comparable costs of care and /or cost-effectiveness ? METHODS We search ed for peer- review ed literature using several bibliographic data bases . In addition , we conducted h and search es of leading telemedicine journals and identified key papers from the reference lists of journal articles . For our original evidence report on telemedicine for the Medicare population , we design ed a search to find any publications about telemedicine and used it to search the MEDLINE , CINAHL , and HealthSTAR data bases for all years the data bases were available . Through this process , we captured studies of pediatric , obstetric , and clinician-indirect home telemedicine ; however , they were excluded from the original report since they were outside its scope . For this supplemental report , we review ed our original search results and identified studies relevant to this report . We identified additional studies from the reference lists of included papers and from h and search ing two peer- review ed telemedicine publications , the Journal of Telemedicine and Telecare and Telemedicine Journal . We critically appraised the included studies for each study area and key question and discussed the strengths and limitations of the most important studies at weekly meetings of the research team . We also developed recommendations for research to address telemedicine knowledge gaps . To match these gaps with the capabilities of specific research methods , we classified the telemedicine services according to the type of evidence that would be needed to determine whether the specific goals of covering such services had been met . We emphasized the relationship between the type and level of evidence found in the systematic review of effectiveness and the types of studies that might be funded to address the gaps in knowledge in this growing field of research . FINDINGS We identified a total of 28 eligible studies . In the new clinical areas , we found few studies in store- and -forward telemedicine . There is some evidence of comparable diagnosis and management decisions made using store- and -forward telemedicine from the areas of pediatric dental screening , pediatric ophthalmology , and neonatalogy . In self-monitoring/testing telemedicine for the areas of pediatrics , obstetrics , and clinician-indirect home telemedicine , there is evidence that access to care can be improved when patients and families have the opportunity to receive telehealth care at home rather than in-person care in a clinic or hospital . Access is particularly enhanced when the telehealth system enables timely communication between patients or families and care providers that allows self-management and necessary adjustments that may prevent hospitalization . There is some evidence that this form of telemedicine improves health outcomes , but the study sample sizes are usually small , and even when they are not , the treatment effects are small . There is also some evidence for the efficacy of clinician-interactive telemedicine , but the studies do not clearly define which technologies provide benefit or cost-efficiency . Some promising areas for diagnosis include emergency medicine , psychiatry , and cardiology . Most of the studies measuring access to care provide evidence that it is improved . Although none of these studies were r and omized controlled trials , they provide some evidence of access improvement over prior conditions . Clinician-interactive telemedicine was the only area for which any cost studies were found . The three cost studies did not adequately demonstrate that telemedicine reduces costs of care ( except comparing only selected costs ) . No study addressed cost-effectiveness . CONCLUSIONS This supplemental report covering the areas of pediatrics , obstetrics , and indirect-clinician home telemedicine echoes the findings of our initial report for the Medicare domain , which is that while the use of telemedicine is small but growing , the evidence for its efficacy is incomplete . Many of the studies are small and /or method ologically limited , so it can not be determined whether telemedicine is efficacious . Future studies should focus on the use of telemedicine in conditions where burden of illness and /or barriers to access for care are significant . Use of recent innovations in the design of r and omized controlled trials for emerging technologies would lead to higher quality studies . Journals publishing telemedicine evaluation studies must set high st and ards for method ologic quality so that evidence reports need not rely on studies with marginal method ologies Background Recent evidence from a large scale trial conducted in the United States indicates that enhancing shared decision-making and improving knowledge , self-management , and provider communication skills to at-risk patients can reduce health costs and utilisation of healthcare re sources . Although this trial has provided a significant advancement in the evidence base for disease management programs it is still left for such results to be replicated and /or generalised for population s in other countries and other healthcare environments . This trial responds to the limited analyses on the effectiveness of providing chronic disease management services through telephone health coaching in Australia . The size of this trial and it 's assessment of cost utility with respect to potentially preventable hospitalisations adds significantly to the body of knowledge to support policy and investment decisions in Australia as well as to the international debate regarding the effect of disease management programs on financial outcomes . Methods Intention to treat study applying a prospect i ve r and omised design comparing usual care with extensive outreach to encourage use of telephone health coaching for those people identified from a risk scoring algorithm as having a higher likelihood of future health costs . The trial population has been limited to people with one or more of the following selected chronic conditions : namely , low back pain , diabetes , coronary artery disease , heart failure , and chronic obstructive pulmonary disease . This trial will enrol at least 64,835 source d from the approximately 3 million Bupa Australia private health insured members located across Australia . The primary outcome will be the total ( non-maternity ) cost per member as reported to the private health insurer ( i.e. charged to the insurer ) 12 months following entry into the trial for each person . Study recruitment will be completed in early 2012 and the results will be available in late 2013 . Discussion If positive , CAPICHe will represent a potentially cost-effective strategy to improve health outcomes in higher risk individuals with a chronic condition , in a private health insurance setting .Trial Registration Australian New Zeal and Clinical Trials Registry reference : In Tlaxcala State , Mexico , we determined that 80 % of children who died from diarrhoea or acute respiratory infections ( ARI ) received medical care before death ; in more than 70 % of the cases this care was provided by a private physician . Several strategies have been developed to improve physicians ' primary health care practice s but private practitioners have only rarely been included . The objective of the present study was to evaluate the impact of in-service training on the case management of diarrhoea and ARI among under-5-year-olds provided by private and public primary physicians . The training consisted of a five-day course of in-service practice during which physicians diagnosed and treated sick children attending a centre and conducted clinical discussion s of cases under guidance . Each training course was limited to six physicians . Clinical performance was evaluated by observation before and after the courses . The evaluation of diarrhoea case management covered assessment of dehydration , hydration therapy , prescription of antimicrobial and other drugs  , advice on diet , and counselling for mothers ; that of ARI case management covered diagnosis , decisions on antimicrobial therapy , use of symptomatic drugs , and counselling for mothers . In general the performance of public physicians both before and after the intervention was better than that of private doctors . Most aspects of the case management of children with diarrhoea improved among both groups of physicians after the course ; the proportion of private physicians who had five or six correct elements out of six increased from 14 % to 37 % : for public physicians the corresponding increase was from 53 % to 73 % . In ARI case management , decisions taken on antimicrobial therapy and symptomatic drug use improved in both groups ; the proportion of private physicians with at least three correct elements out of four increased from 13 % to 42 % , while among public doctors the corresponding increase was from 43 % to 78 % . H and s-on training courses thus seemed to be effective in improving the practice of physicians in both the private and public sectors The prevalence of anxiety disorders is increased among low-income individuals , who are more likely to seek mental health care in medical as opposed to specialty setting s because of limited insurance access and restricted availability of public sector mental health re sources . However , little is known about the clinical characteristics and illness severity of anxiety disorders in this setting . We studied the clinical characteristics of  low-income compared with middle-income primary care panic patients .  Clinical , functional , and service use measures obtained at baseline interview in 39 panic disorder patients seen in one public sector medical clinic were compared with 76 patients seen in two middle-income clinics . All patients were participants in a r and omized effectiveness pharmacotherapy trial [ Roy Byrne et al. , Arch Gen Psychiatry 2001;58:869 - 876 ] . Public sector patients were more often older , male , single , unemployed , of lower income , and non-Caucasian ethnicity . They had more severe clinical symptoms , more medical comorbidity , worse physical and role health status , and more emergency room visits . Low income and unemployment accounted for most of the differences in non-anxiety-related measures . However , type of clinic still contributed independently to the greater severity of specific measures of panic/anxiety ( Panic Disorder Severity Scale and Marks Fear Scale scores ) , suggesting that the increased stress and limited social re sources associated with low-income and disadvantaged status may have more specific effects on anxiety than other aspects of psychopathology Background Malaria is a major public health problem in Ug and a and the current policy recommends introduction of rapid diagnostic tests for malaria ( RDTs ) to facilitate effective case management . However , provision of RDTs in drug shops potentially raises a new set of issues , such as adherence to RDTs results , management of severe illnesses , referral of patients , and relationship with caretakers . The main objective of the study was to examine the impact of introducing  RDTs in registered drug shops in Ug and a and document lessons and policy implication s for future scale-up of malaria control in the private health sector . Methods A cluster-r and omized trial introducing RDTs into registered drug shops was implemented in central Ug and a from October 2010 to July 2012 . An evaluation was undertaken to assess the impact and the processes involved with the introduction of RDTs into drug shops , the lessons learned and policy implication s. Results Introducing RDTs into drug shops was feasible . To scale-up this intervention however , drug shop practice s need to be regulated since the registration process was not clear , supervision was inadequate and record keeping was poor . Although initially it was anticipated that introducing a new practice of record keeping would be cumbersome , but at evaluation this was not found to be a constraint . This presents an important lesson for introducing health management information system into drug shops . Involving stakeholders , especially the district health team , in the design was important for ownership and sustainability . The involvement of village health teams in community sensitization to the new malaria treatment and diagnosis policy was a success and this strategy is recommended for future interventions . Conclusion Introducing RDTs into drug shops was feasible and it increased appropriate treatment of malaria with artemisinin-based combination therapy . It is anticipated that the lessons presented will help better implementation of similar interventions in the private sector
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 .