Explore the vast range of titles available.

Half the world's people currently live in rural and remote areas. The problem is that most health workers live and work in cities. This imbalance is common to almost all countries and poses a major challenge to the nationwide provision of health services. Its impact, however, is most severe in low income countries. There are two reasons for this. One is that many of these countries already suffer from acute shortages of health workers - in all areas. The other is that the proportion of the population living in rural regions tends to be greater in poorer countries than in rich ones. The World Health Organization (WHO) has therefore drawn up a comprehensive set of strategies to help countries encourage health workers to live and work in remote and rural areas. These include refining the ways students are selected and educated, as well as creating better working and living conditions. The first step has been to establish what works, through a year-long process that has involved a wide range of experts from all regions of the world. The second is to share the results with those who need them, via the guidelines contained in this document. The third will be to implement them, and to monitor and evaluate progress, and - critically - to act on the findings of that monitoring and evaluation. The guidelines are a practical tool that all countries can use. As such, they complement the WHO Global Code of Practice on the International Recruitment of Health Personnel, adopted by the Sixty-third World Health Assembly in May 2010. The Code offers a framework to manage international migration over the medium to longer term. The guidelines are a tool that can be used straight away to address one of the first triggers to internal and international migration - dissatisfaction with living and working conditions in rural areas. Together, the code of practice and these new guidelines provide countries with instruments to improve workforce distribution and enhance health services. Doing so will address a long-standing problem, contribute to more equitable access to health care, and boost prospects for improving maternal and child health and combating diseases such as AIDS, tuberculosis and malaria.

Assistance by skilled birth attendants (SBAs) during childbirth is one of the strategies aimed at reducing maternal morbidity and mortality in low-income countries. However, the relationship between birth preparedness and decision-making on location of birth and assistance by skilled birth attendants in this context is not well studied. The aim of this study was to assess the influence of birth preparedness practices and decision-making and assistance by SBAs among women in south-western Uganda. Community survey methods were used to identify 759 recently delivered women from 120 villages in rural Mbarara district. Interviewer-administered questionnaires were used to collect data. Logistic regression analyses were conducted to assess the relationship between birth preparedness, decision-making on location of birth and assistance by SBAs. 35% of the women had been prepared for childbirth and the prevalence of assistance by SBAs in the sample was 68%. The final decision regarding location of birth was made by the woman herself (36%), the woman with spouse (56%) and the woman with relative/friend (8%). The relationships between birth preparedness and women decision-making on location of birth in consultation with spouse/friends/relatives and choosing assistance by SBAs showed statistical significance which persisted after adjusting for possible confounders (OR 1.5, 95% CI: 1.0-2.4) and (OR 4.4, 95% CI: 3.0-6.7) respectively. Education, household assets and birth preparedness showed clear synergistic effect on the relationship between decision-maker on location of birth and assistance by SBAs. Other factors which showed statistical significant relationships with assistance by SBAs were ANC attendance, parity and residence. Women's decision-making on location of birth in consultation with spouse/friends/relatives and birth preparedness showed significant effect on choosing assistance by SBAs at birth. Education and household assets ownership showed a synergistic effect on the relationship between the decision-maker and assistance by SBAs.

Background Waiting times for hospital appointments, treatment and/or surgery have become a major political and health service problem, leading to national maximum waiting times and policies to reduce waiting times. Quantitative studies have documented waiting times for various types of surgery and longer waiting times in public vs private hospitals. However, very little qualitative research has explored patient experiences of waiting, how this compares between public and private hospitals, and the implications for trust in hospitals and healthcare professionals. The aim of this paper is to provide a deep understanding of the impact of waiting times on patient trust in public and private hospitals. Methods A qualitative study in South Australia, including 36 in-depth interviews (18 from public and 18 from private hospitals). Data collection occurred in 2012–13, and data were analysed using pre-coding, followed by conceptual and theoretical categorisation. Results Participants differentiated between experiences of ‘waiting for’ (e.g. for specialist appointments and surgery) and ‘waiting in’ (e.g. in emergency departments and outpatient clinics) public and private hospitals. Whilst ‘waiting for’ public hospitals was longer than private hospitals, this was often justified and accepted by public patients (e.g. due to reduced government funding), therefore it did not lead to distrust of public hospitals. Private patients had shorter ‘waiting for’ hospital services, increasing their trust in private hospitals and distrust of public hospitals. Public patients also recounted many experiences of longer ‘waiting in’ public hospitals, leading to frustration and anxiety, although they rarely blamed or distrusted the doctors or nurses, instead blaming an underfunded system and over-worked staff. Doctors and nurses were seen to be doing their best, and therefore trustworthy. Conclusion Although public patients experienced longer ‘waiting for’ and ‘waiting in’ public hospitals, it did not lead to widespread distrust in public hospitals or healthcare professionals. Private patients recounted largely positive stories of reduced ‘waiting for’ and ‘waiting in’ private hospitals, and generally distrusted public hospitals. The continuing trust by public patients in the face of negative experiences may be understood as a form of exchange trust norm , in which institutional trust is based on base-level expectations of consistency and minimum standards of care and safety. The institutional trust by private patients may be understood as a form of communal trust norm , whereby trust is based on the additional and higher-level expectations of flexibility, reduced waiting and more time with healthcare professionals.

To compare the cost-effectiveness of the tuberculosis (TB) programme run by the Bangladesh Rural Advancement Committee (BRAC), which uses community health workers (CHWs), with that of the government TB programme which does not use CHWs. TB control statistics and cost data for July 1996 - June 1997 were collected from both government and BRAC thanas (subdistricts) in rural Bangladesh. To measure the cost per patient cured, total costs were divided by the total number of patients cured. In the BRAC and government areas, respectively, a total of 186 and 185 TB patients were identified over one year, with cure rates among sputum-positive patients of 84% and 82%. However, the cost per patient cured was US$ 64 in the BRAC area compared to US$ 96 in the government area. The government programme was 50% more expensive for similar outcomes. Although both the BRAC and government TB control programmes appeared to achieve satisfactory cure rates using DOTS (a five-point strategy), the involvement of CHWs was found to be more cost-effective in rural Bangladesh. With the same budget, the BRAC programme could cure three TB patients for every two in the government programme.

A wide variety of information sources on medicines is available for pregnant women. When using multiple information sources, there is the risk that information will vary or even conflict. The objective of this multinational study was to analyze the extent to which pregnant women use multiple information sources and the consequences of conflicting information, and to investigate which maternal sociodemographic, lifestyle, and medical factors were associated with these objectives. An anonymous Internet-based questionnaire was made accessible during a period of 2 months, on 1 to 4 Internet websites used by pregnant women in 5 regions (Eastern Europe, Western Europe, Northern Europe, Americas, Australia). A total of 7092 responses were obtained (n=5090 pregnant women; n=2002 women with a child younger than 25 weeks). Descriptive statistics and logistic regression analysis were used. Of the respondents who stated that they needed information, 16.16% (655/4054) used one information source and 83.69% (3393/4054) used multiple information sources. Of respondents who used more than one information source, 22.62% (759/3355) stated that the information was conflicted. According to multivariate logistic regression analysis, factors significantly associated with experiencing conflict in medicine information included being a mother (OR 1.32, 95% CI 1.11-1.58), having university (OR 1.33, 95% CI 1.09-1.63) or other education (OR 1.49, 95% CI 1.09-2.03), residing in Eastern Europe (OR 1.52, 95% CI 1.22-1.89) or Australia (OR 2.28, 95% CI 1.42-3.67), use of 3 (OR 1.29, 95% CI 1.04-1.60) or >4 information sources (OR 1.82, 95% CI 1.49-2.23), and having ≥2 chronic diseases (OR 1.49, 95% CI 1.18-1.89). Because of conflicting information, 43.61% (331/759) decided not to use medication during pregnancy, 30.30% (230/759) sought a new information source, 32.67% (248/759) chose to rely on one source and ignore the conflicting one, 25.03% (190/759) became anxious, and 2.64% (20/759) did nothing. Factors significantly associated with not using medication as a consequence of conflicting information were being pregnant (OR 1.75, 95% CI 1.28-2.41) or experiencing 3-4 health disorders (OR 1.99, 95% CI 1.10-3.58). Women with no chronic diseases were more likely not to take medicines than women with ≥2 chronic diseases (OR 2.22, 95% CI 1.47-3.45). Factors significantly associated with becoming anxious were >4 information sources (OR 2.67, 95% CI 1.70-4.18) and residing in Eastern Europe (OR 0.57, 95% CI 0.36-0.90). Almost all the pregnant women used multiple information sources when seeking information on taking medicines during pregnancy and one-fifth obtained conflicting information, leading to anxiety and the decision not to use the medication. Regional, educational, and chronic disease characteristics were associated with experiencing conflicting information and influenced the decision not to use medication or increased anxiety. Accurate and uniform teratology information should be made more available to the public.

This study contributes to the health policy debate on medical systems integration by describing and analysing the interactions between health-care users, indigenous healers, and the biomedical public health system, in the so far rarely documented case of post-conflict Burundi. We adopt a mixed-methods approach combining (1) data from an existing survey on access to health-care, with 6,690 individuals, and (2) original interviews and focus groups conducted in 2014 with 121 respondents, including indigenous healers, biomedical staff, and health-care users. The findings reveal pluralistic patterns of health-care seeking behaviour, which are not primarily based on economic convenience or level of education. Indigenous healers’ diagnosis is shown to revolve around the concept of ‘enemy’ and the need for protection against it. We suggest ways in which this category may intersect with the widespread experience of trauma following the civil conflict. Finally, we find that, while biomedical staff displays ambivalent attitudes towards healers, cross-referrals occasionally take place between healers and health centres. These findings are interpreted in light of the debate on health systems integration in Sub-Saharan Africa. In particular, we discuss policy options regarding healers’ accreditation, technical training, management of cross-referrals as well as of herb-drug interactions; and we emphasise healers’ psychological support role in helping communities deal with trauma. In this respect, we argue that the experience of conflict, and the experiences and conceptualizations of mental and physical illness, need to be taken into account when devising appropriate public or international health policy responses. La présente étude est une contribution au débat politique sur l’intégration des systèmes médicaux en décrivant et en analysant les interactions entre les utilisateurs des soins de santé, les guérisseurs indigènes et le système biomédical de santé publique, dans le contexte si peu documenté du Burundi post-conflit. Nous adoptons une approche mixte combinant 1) les données d’une enquête existante sur l’accès aux soins, portant sur 6 690 personnes, et 2) des entretiens inédits et des discussions de groupes menés en 2014 auprès de 121 répondants, notamment les guérisseurs traditionnels, le personnel biomédical, et les utilisateurs des soins de santé. Les résultats révèlent divers modèles de comportement en matière de recherche des soins de santé, qui ne sont pas fondés sur des raisons purement économiques ou sur le niveau d’éducation. Le diagnostic des guérisseurs traditionnels s’articule autour de la notion d’«ennemi» et de la nécessité de s’en protéger. Nous proposons des moyens par lesquels cette catégorie peut entrecroiser l’expérience largement répandue du traumatisme subi à la suite de la guerre civile. Enfin, nous constatons que, bien que le personnel biomédical affiche des attitudes ambivalentes à l’égard des guérisseurs, ceux-ci orientent parfois les malades vers les centres de santé et vice-versa. Ces résultats sont interprétés à la lumière du débat sur l’intégration des systèmes de santé en Afrique subsaharienne. Nous débattons en particulier des options politiques concernant l’accréditation des guérisseurs, la formation technique, la gestion de l’orientation mutuelle des patients ainsi que des interactions des plantes médicinales; et nous soulignons le rôle de soutien psychologique des guérisseurs traditionnels qui aident les communautés à faire face au traumatisme. À ce propos, nous soutenons que l’expérience du conflit, ainsi que les expériences et les conceptualisations des maladies mentales et physiques, doivent être prises en compte lors de l’élaboration de politiques appropriées de santé publique ou internationale. 本文描述和分析了冲突后布隆迪的卫生服务使用者、民间治 疗师和生物医学（西医）公共卫生体系之间的互动, 从而为医 疗体系整合的卫生政策论争提供新见解。我们采用了混合方 法, 结合 （1） 现有的关于卫生可及性的调查数据, 包含6690 名参与者, （2） 2014年进行的访谈和焦点小组讨论, 包含121 名受访者, 包括民间治疗师、西医人员和卫生服务使用者。研 究结果显示, 求医行为呈现多元化模式, 并且主要不是受经济 便利程度或教育水平影响。民间治疗师的诊断围绕着“敌 方”这一概念, 以及抵御其危害的必要性。我们提出了这一分 类如何与内战所致的广泛创伤体验相互交叉。最后, 我们发 现, 尽管西医人员对民间治疗师的看法很矛盾, 但双方互相转 诊的情况偶有发生。对研究发现的理解考虑到了撒哈拉以南 非洲地区卫生体系整合的论争背景。我们特别探讨了民间治 疗师认证、技术培训、交叉转诊管理及草药-西药相互作用的 政策选择, 强调治疗师在帮助社区应对创伤时的心理支持作 用。我们认为在设计适宜的公共或国际卫生政策时, 需要考虑 冲突的情况, 以及心理和生理疾病的经历和概念化。 Este estudio contribuye al debate de políticas de salud sobre la integración de los sistemas médicos describiendo y analizando las interacciones entre los usuarios de los servicios de salud, los curanderos indígenas y el sistema de salud pública biomédica, en el caso hasta ahora poco documentado de Burundi post-conflicto. Adoptamos un enfoque de métodos mixtos combinando (1) los datos de una encuesta existente sobre acceso a servicios de salud, con 6.690 personas, y (2) entrevistas originales y grupos focales realizados en 2014 con 121 encuestados, incluyendo curanderos indígenas, personal biomédico, y usuarios de la atención de salud. Los hallazgos revelan tendencias pluralistas del comportamiento de la búsqueda de la atención de salud, que no se basan principalmente en la conveniencia económica o el nivel de educación. El diagnóstico de los curanderos indígenas gira en torno al concepto de ‘enemigo’ y la necesidad de protección contra este. Sugerimos formas en las cuales esta categoría se puede intersectar con la experiencia generalizada del trauma después del conflicto civil. Finalmente, encontramos que, si bien el personal biomédico muestra actitudes ambivalentes hacia los curanderos, ocasionalmente se producen referencias cruzadas entre los curanderos y los centros de salud. Estos hallazgos se interpretan en el contexto del debate sobre la integración de los sistemas de salud en el África subsahariana. En particular, discutimos las opciones de políticas con respecto a la acreditación de los curanderos, la capacitación técnica, la gestión de referencias cruzadas, así como de las interacciones entre las hierbas y los medicamentos; y enfatizamos el papel del apoyo psicológico de los curanderos para ayudar a las comunidades a lidiar con el trauma. De esta manera, sostenemos que la experiencia del conflicto y las experiencias y conceptualizaciones de las enfermedades mentales y físicas deben tenerse en cuenta a la hora de diseñar respuestas de políticas de salud pública o internacional apropiada.

Background Reducing maternal morbidity and mortality is a global priority which is particularly relevant to developing countries like Ethiopia. One of the key strategies for reducing maternal morbidity and mortality is increasing institutional delivery service utilization of mothers under the care of skilled birth attendants. The aim of this study was to determine the level of institutional delivery service utilization and associated factors. Methods A community-based cross-sectional survey was conducted from April 1–20, 2011, among mothers who gave birth 12 months before the study began in Munesa Woreda, Arsi Zone, Oromia Region, Southeast Ethiopia. A stratified cluster sampling was used to select a sample of 855 participants. Results Out of all deliveries, only 12.3% took place at health facilities. Women who were urban residents (AOR = 2.27, 95%CI: 1.17, 4.40), women of age at interview less than 20 years (AOR = 6.06, 95%CI: 1.54, 23.78), women with first pregnancy (AOR = 2.41, 95%CI: 1.17, 4.97) and, women who had ANC visit during the last pregnancy (AOR = 4.18, 95%CI: 2.54, 6.89) were more likely to deliver at health institutions. Secondary and above level of mother`s and husband`s education had also a significant effect on health institution delivery with AOR = 4.31 (95%CI: 1.62, 11.46) and AOR = 2.77 (95%CI: 1.07, 7.19) respectively. Conclusion Institutional delivery service utilization was found to be low in the study area. Secondary and above level of mother`s and husband`s education, urban residence and ANC visit were amongst the main factors that had an influence on health institution delivery. Increasing the awareness of mothers and their partners about the benefits of institutional delivery services are recommended.

Evidence supports the implementation of task shifting to address health worker shortages that are common in resource-limited settings. However, there is need to learn from established programs to identify ways to achieve the strongest, most sustainable impact. This study examined the Botswana lay counselor cadre, a task shifting initiative, to explore effectiveness and contribution to the health workforce. This evaluation used multiple methods, including a desk review, a national lay counselor survey (n = 385; response = 94%), in-depth interviews (n = 79), lay counselors focus group discussions (n = 7), lay counselors observations (n = 25), and client exit interviews (n = 47). Interview and focus group data indicate that lay counselors contribute to essentially all HIV-related programs in Botswana and they conduct the majority of HIV tests and related counseling at public health facilities throughout the country. Interviews showed that the lay counselor cadre is making the workload of more skilled health workers more manageable and increasing HIV acceptance in communities. The average score on a work-related knowledge test was 74.5%. However for 3 questions, less than half answered correctly. During observations, lay counselors demonstrated average competence for most skills assessed and clients (97.9%) were satisfied with services received. From the survey, lay counselors generally reported being comfortable with their duties; however, some reported clinical duties that extended beyond their training and mandate. Multiple factors affecting the performance of the lay counselors were identified, including insufficient resources, such as private counseling space and HIV test kits; and technical, administrative, and supervisory support. Lay counselors are fulfilling an important role in Botswana's healthcare system, serving as the entry point into HIV care, support, and treatment services. For this and other similar task shifting initiatives, it is important that lay counselors' responsibilities are clear and that training and support are adequate to optimize their effectiveness.

The government of Tanzania has adopted voluntary medical male circumcision (VMMC) as an important component of its national HIV prevention strategy and is scaling up VMMC in eight regions nationwide, with the goal of reaching 2.8 million uncircumcised men by 2015. In a 2010 campaign lasting six weeks, five health facilities in Tanzania's Iringa Region performed 10,352 VMMCs, which exceeded the campaign's target by 72%, with an adverse event (AE) rate of 1%. HIV testing was almost universal during the campaign. Through the adoption of approaches designed to improve clinical efficiency-including the use of the forceps-guided surgical method, the use of multiple beds in an assembly line by surgical teams, and task shifting and task sharing-the campaign matched the supply of VMMC services with demand. Community mobilization and bringing client preparation tasks (such as counseling, testing, and client scheduling) out of the facility and into the community helped to generate demand. This case study suggests that a campaign approach can be used to provide high-volume quality VMMC services without compromising client safety, and provides a model for matching supply and demand for VMMC services in other settings.

Background Although extra pulmonary tuberculosis (EPTB) has long been known as a major public health concern globally, the complex healthcare-seeking pathways of EPTB patients are not widely studied. This study aims to explore the pattern of healthcare-seeking pathways of rural and urban EPTB patients registered with the BRAC TB control programme. BRAC is a Bangladesh-based non-governmental organization dedicated to alleviating poverty through empowering the poor. Method Data were collected through 60 in-depth interviews with rural and urban EPTB patients in Bangladesh. Results The findings reveal that the rural EPTB patients encountered a substantial diagnostic delay as compared to the urban patients. However, the difference between the average number of healthcare providers consulted by the rural verses the urban EPTB patients was not significant. This study also shows that the healthcare-seeking journey of rural and urban EPTB patients usually starts either at pharmacies or private facilities. Through exploring the detailed nature of the pathway, this study reveals the ways in which non-medical informants, mainly relatives and friends, can benefit patients. Conclusions The private and informal healthcare providers should receive appropriate training on the diagnosis of EPTB. Such training could effectively shorten the long and complex healthcare-seeking pathways of EPTB patients.