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Dhaka, Bangladesh

Guinness L.,London School of Hygiene and Tropical Medicine | Vickerman P.,London School of Hygiene and Tropical Medicine | Quayyum Z.,University of Aberdeen | Foss A.,London School of Hygiene and Tropical Medicine | And 5 more authors.

Aims To assess the cost-effectiveness of the CARE-SHAKTI harm reduction intervention for injecting drug users (IDUs) over a 3-year period, the impact on the cost-effectiveness of stopping after 3 years and how the cost-effectiveness might vary with baseline human immunodeficiency virus (HIV) prevalence. Design Economic cost data were collected from the study site and combined with impact estimates derived from a dynamic mathematical model. Setting Dhaka, Bangladesh, where the HIV prevalence has remained low despite high-risk sexual and injecting behaviours, and growing HIV epidemics in neighbouring countries. Findings The cost per HIV infection prevented over the first 3 years was US$110.4 (33.1-182.3). The incremental cost-effectiveness of continuing the intervention for a further year, relative to stopping at the end of year 3, is US$97 if behaviour returns to pre-intervention patterns. When baseline IDU HIV prevalence is increased to 40%, the number of HIV infections averted is halved for the 3-year period and the cost per HIV infection prevented doubles to US$228. Conclusions The analysis confirms that harm reduction activities are cost-effective. Early intervention is more cost-effective than delaying activities, although this should not preclude later intervention. Starting harm reduction activities when IDU HIV prevalence reaches as high as 40% is still cost-effective. Continuing harm reduction activities once a project has matured is vital to sustaining its impact and cost-effectiveness. © 2009 Society for the Study of Addiction. Source

Ahmed S.M.,Research and Evaluation Division | Hossain M.A.,Research and Evaluation Division | RajaChowdhury A.M.,Brac University | Bhuiya A.U.,ICDDRB
Human Resources for Health

Background: Bangladesh is identified as one of the countries with severe health worker shortages. However, there is a lack of comprehensive data on human resources for health (HRH) in the formal and informal sectors in Bangladesh. This data is essential for developing an HRH policy and plan to meet the changing health needs of the population. This paper attempts to fill in this knowledge gap by using data from a nationally representative sample survey conducted in 2007.Methods: The study population in this survey comprised all types of currently active health care providers (HCPs) in the formal and informal sectors. The survey used 60 unions/wards from both rural and urban areas (with a comparable average population of approximately 25 000) which were proportionally allocated based on a 'Probability Proportion to Size' sampling technique for the six divisions and distribution areas. A simple free listing was done to make an inventory of the practicing HCPs in each of the sampled areas and cross-checking with community was done for confirmation and to avoid duplication. This exercise yielded the required list of different HCPs by union/ward.Results: HCP density was measured per 10 000 population. There were approximately five physicians and two nurses per 10 000, the ratio of nurse to physician being only 0.4. Substantial variation among different divisions was found, with gross imbalance in distribution favouring the urban areas. There were around 12 unqualified village doctors and 11 salespeople at drug retail outlets per 10 000, the latter being uniformly spread across the country. Also, there were twice as many community health workers (CHWs) from the non-governmental sector than the government sector and an overwhelming number of traditional birth attendants. The village doctors (predominantly males) and the CHWs (predominantly females) were mainly concentrated in the rural areas, while the paraprofessionals were concentrated in the urban areas. Other data revealed the number of faith/traditional healers, homeopaths (qualified and non-qualified) and basic care providers.Conclusions: Bangladesh is suffering from a severe HRH crisis--in terms of a shortage of qualified providers, an inappropriate skills-mix and inequity in distribution--which requires immediate attention from policy makers. © 2011 Ahmed et al; licensee BioMed Central Ltd. Source

Agency: GTR | Branch: MRC | Program: | Phase: Research Grant | Award Amount: 133.98K | Year: 2015

Improving the quality of care is emphasized in maternal and neonatal health (MNH) to enhance efficacy and effectiveness of interventions. However, there is neither any globally accepted definition, nor any standardized tool to monitor quality of care in MNH. Bangladesh is on-track in achieving the targets for Millennium Development Goal 4 & 5 with low institutional delivery rate (29%), the majority (18%) of which takes place in for-profit private sector facilities. Poor quality of care in public facilities compels pregnant women to use private facilities which may lead to catastrophic health expenditure. Users may perceive services from private sector facilities to be superior to services from public facilities due to incentive mechanism. The unregulated private sector is growing fast in the country and there are reports of overcharging and unnecessary caesarean sections in the private facilities. Dual practice is common among public sector providers and referral from public to private for financial benefit is not uncommon. Governance is weak to oversee the pluralistic health system where the private sector is increasingly contributing in the health care delivery. Innovative systems approach needed for better integration of private sector inputs to maximize their contribution in achieving the national public health goals. Audit and feedback has demonstrated its feasibility and effectiveness in improving providers performances in clinical settings in high-income countries. Several global programs such as JHPIEGO (Johns Hopkins Program for International Education in Gynecology and Obstetrics) and AMDD (Averting Maternal Death and Disability) of the Columbia University have developed tools to monitor and improve quality of MNH care. In this study we plan to review the existing audit and quality improvement tools to adapt them in Bangladesh to test its feasibility, acceptability and effectiveness in improving quality of MNH care following a district health systems approach. The study will be conducted in a medium performing district of Bangladesh following a mixed method, pretest-post-test research design .The tools developed, will be contextualized through multiple stakeholders consultations and finalized after pretesting in a hypothetical field outside the study district. A baseline study will be conducted for needs assessment and benchmarking the quality indicators in public and private sector hospitals for future evaluations. Baseline study will include SWOT and Stakeholders Analysis to understand the context and building broader alliance to facilitate the implementation of the designed interventions. District Quality Assurance (QA) Team will be formed involving key stakeholders in the district, including the users. Developed monitoring and feedback tool will include key quality indicators covering structure, process and outcome dimensions of quality of care and will be implemented through joint quarterly visit of all public and private facilities by the district QA team members. Feedback will be given every 6 monthly through workshops and periodic quality monitoring reports. Process documentation will be the key method for evaluation. Qualitative Key Informants Interviews with explore the enabling and constraining factors impacting both implementation and making changes in quality of MNH care. The quantitative pre and post intervention surveys will be the other methods for assessing the change in quality of care (both technical and perceived) due to introduction of stakeholders monitoring and feedback. A costing exercise will measure the cost of interventions to inform policy for scale-up and sustainability. Study outcome will be communicated to target audience using multiple channels such as journal articles, conference abstracts, policy briefs and newspaper articles. An implementation research protocol will be developed to inform policy for future scale-up nationwide to impact maternal and neonatal health outcomes.

Kirkpatrick B.D.,University of Vermont | Colgate E.R.,University of Vermont | Mychaleckyj J.C.,University of Virginia | Haque R.,ICDDRB | And 11 more authors.
American Journal of Tropical Medicine and Hygiene

Oral vaccines appear less effective in children in the developing world. Proposed biologic reasons include concurrent enteric infections, malnutrition, breast milk interference, and environmental enteropathy (EE). Rigorous study design and careful data management are essential to begin to understand this complex problem while assuring research subject safety. Herein, we describe the methodology and lessons learned in the PROVIDE study (Dhaka, Bangladesh). A randomized clinical trial platform evaluated the efficacy of delayed-dose oral rotavirus vaccine as well as the benefit of an injectable polio vaccine replacing one dose of oral polio vaccine. This rigorous infrastructure supported the additional examination of hypotheses of vaccine underperformance. Primary and secondary efficacy and immunogenicity measures for rotavirus and polio vaccines were measured, as well as the impact of EE and additional exploratory variables. Methods for the enrollment and 2-year follow-up of a 700 child birth cohort are described, including core laboratory, safety, regulatory, and data management practices. Intense efforts to standardize clinical, laboratory, and data management procedures in a developing world setting provide clinical trials rigor to all outcomes. Although this study infrastructure requires extensive time and effort, it allows optimized safety and confidence in the validity of data gathered in complex, developing country settings. Copyright © 2015 by The American Society of Tropical Medicine and Hygiene. Source

Rahman M.,ICDDRB | Rahman M.,Columbia University | Sohel N.,ICDDRB | Sohel N.,McMaster University | And 6 more authors.

Background: Arsenic in drinking water was associated with increased risk of all-cause, cancer, and cardiovascular death in adults. However, the extent to which exposure is related to all-cause and deaths from cancer and cardiovascular condition in young age is unknown. Therefore, we prospectively assessed whether long-term and recent arsenic exposures are associated with all-cause and cancer and cardiovascular mortalities in Bangladeshi childhood population. Methods and Findings: We assembled a cohort of 58406 children aged 5-18 years from the Health and Demographic Surveillance System of icddrb in Bangladesh and followed during 2003-2010. There were 185 non-accidental deaths registered in-about 0.4 million person-years of observation. We calculated hazard ratios for cause-specific death in relation to exposure at baseline (μg/L), time-weighted lifetime average (μg/L) and cumulative concentration (μg-years/L). After adjusting covariates, hazard ratios (HRs) for all-cause childhood deaths comparing lifetime average exposure 10-50.0, 50.1-150.0, 150.1-300.0 and ≥300.1μg/L were 1.37 (95% confidence interval [CI], 0.74-2.57), 1.44 (95% CI, 0.88-2.38), 1.22 (95% CI, 0.75-1.98) and 1.88 (95% CI, 1.14-3.10) respectively. Significant increased risk was also observed for baseline (P for trend = 0.023) and cumulative exposure categories (P for trend = 0.036). Girls had higher mortality risk compared to boys (HR for girls 1.79, 1.21, 1.64, 2.31; HR for boys 0.52, 0.53, 1.14, 0.99) in relation to baseline exposure. For all cancers and cardiovascular deaths combined, multivariable adjusted HRs amounted to 1.53 (95% CI 0.51-4.57); 1.29 (95% CI 0.43-3.87); 2.18 (95%CI 1.15-4.16) for 10.0-50.0, 50.1-150.0, and ≥150.1, comparing lowest exposure as reference (P for trend = 0.009). Adolescents had higher mortality risk compared to children (HRs = 1.53, 95% CI 1.03-2.28 vs. HRs = 1.30, 95% CI 0.78-2.17). Conclusions: Arsenic exposure was associated with substantial increased risk of deaths at young age from all-cause, and cancers and cardiovascular conditions. Girls and adolescents (12-18 years) had higher risk compared to boys and child. © 2013 Rahman et al. Source

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