Person:

Bloom, David

Background: Urban slums in developing countries that are not recognized by the government often lack legal access to municipal water supplies. This results in the creation of insecure “informal” water distribution systems (i.e., community-run or private systems outside of the government’s purview) that may increase water-borne disease risk. We evaluate an informal water distribution system in a slum in Mumbai, India using commonly accepted health and social equity indicators. We also identify predictors of bacterial contamination of drinking water using logistic regression analysis. Methods: Data were collected through two studies: the 2008 Baseline Needs Assessment survey of 959 households and the 2011 Seasonal Water Assessment, in which 229 samples were collected for water quality testing over three seasons. Water samples were collected in each season from the following points along the distribution system: motors that directly tap the municipal supply (i.e., “point-of-source” water), hoses going to slum lanes, and storage and drinking water containers from 21 households. Results: Depending on season, households spend an average of 52 to 206 times more than the standard municipal charge of Indian rupees 2.25 (US dollars 0.04) per 1000 liters for water, and, in some seasons, 95% use less than the WHO-recommended minimum of 50 liters per capita per day. During the monsoon season, 50% of point-of-source water samples were contaminated. Despite a lack of point-of-source water contamination in other seasons, stored drinking water was contaminated in all seasons, with rates as high as 43% for E. coli and 76% for coliform bacteria. In the multivariate logistic regression analysis, monsoon and summer seasons were associated with significantly increased odds of drinking water contamination. Conclusions: Our findings reveal severe deficiencies in water-related health and social equity indicators. All bacterial contamination of drinking water occurred due to post-source contamination during storage in the household, except during the monsoon season, when there was some point-of-source water contamination. This suggests that safe storage and household water treatment interventions may improve water quality in slums. Problems of exorbitant expense, inadequate quantity, and poor point-of-source quality can only be remedied by providing unrecognized slums with equitable access to municipal water supplies.

Background: Many mathematical models have investigated the impact of expanding access to antiretroviral therapy (ART) on new HIV infections. Comparing results and conclusions across models is challenging because models have addressed slightly different questions and have reported different outcome metrics. This study compares the predictions of several mathematical models simulating the same ART intervention programmes to determine the extent to which models agree about the epidemiological impact of expanded ART. Methods and Findings: Twelve independent mathematical models evaluated a set of standardised ART intervention scenarios in South Africa and reported a common set of outputs. Intervention scenarios systematically varied the CD4 count threshold for treatment eligibility, access to treatment, and programme retention. For a scenario in which 80% of HIV-infected individuals start treatment on average 1 y after their CD4 count drops below 350 cells/µl and 85% remain on treatment after 3 y, the models projected that HIV incidence would be 35% to 54% lower 8 y after the introduction of ART, compared to a counterfactual scenario in which there is no ART. More variation existed in the estimated long-term (38 y) reductions in incidence. The impact of optimistic interventions including immediate ART initiation varied widely across models, maintaining substantial uncertainty about the theoretical prospect for elimination of HIV from the population using ART alone over the next four decades. The number of person-years of ART per infection averted over 8 y ranged between 5.8 and 18.7. Considering the actual scale-up of ART in South Africa, seven models estimated that current HIV incidence is 17% to 32% lower than it would have been in the absence of ART. Differences between model assumptions about CD4 decline and HIV transmissibility over the course of infection explained only a modest amount of the variation in model results. Conclusions: Mathematical models evaluating the impact of ART vary substantially in structure, complexity, and parameter choices, but all suggest that ART, at high levels of access and with high adherence, has the potential to substantially reduce new HIV infections. There was broad agreement regarding the short-term epidemiologic impact of ambitious treatment scale-up, but more variation in longer term projections and in the efficiency with which treatment can reduce new infections. Differences between model predictions could not be explained by differences in model structure or parameterization that were hypothesized to affect intervention impact.

Objective: A focus on bacterial contamination has limited many studies of water service delivery in slums, with diarrheal illness being the presumed outcome of interest. We conducted a mixed methods study in a slum of 12,000 people in Mumbai, India to measure deficiencies in a broader array of water service delivery indicators and their adverse life impacts on the slum’s residents. Methods: Six focus group discussions and 40 individual qualitative interviews were conducted using purposeful sampling. Quantitative data on water indicators—quantity, access, price, reliability, and equity—were collected via a structured survey of 521 households selected using population-based random sampling. Results: In addition to negatively affecting health, the qualitative findings reveal that water service delivery failures have a constellation of other adverse life impacts—on household economy, employment, education, quality of life, social cohesion, and people’s sense of political inclusion. In a multivariate logistic regression analysis, price of water is the factor most strongly associated with use of inadequate water quantity (≤20 liters per capita per day). Water service delivery failures and their adverse impacts vary based on whether households fetch water or have informal water vendors deliver it to their homes. Conclusions: Deficiencies in water service delivery are associated with many non-health-related adverse impacts on slum households. Failure to evaluate non-health outcomes may underestimate the deprivation resulting from inadequate water service delivery. Based on these findings, we outline a multidimensional definition of household “water poverty” that encourages policymakers and researchers to look beyond evaluation of water quality and health. Use of multidimensional water metrics by governments, slum communities, and researchers may help to ensure that water supplies are designed to advance a broad array of health, economic, and social outcomes for the urban poor.

Background: The Global Vaccine Action Plan will require, inter alia, the mobilization of financial resources from donors and national governments – both rich and poor. Vaccine Procurement Assistance (VPA) and Vaccine Procurement Baseline (VPB) are two metrics that could measure government performance and track resources in this arena. VPA is proposed as a new subcategory of Official Development Assistance (ODA) given for the procurement of vaccines and VPB is a previously suggested measure of the share of Gross Domestic Product (GDP) that governments spend on their own vaccine procurement. Objective: To determine realistic targets for VPA and VPB. Methods: Organization for Economic Co-Operation and Development (OECD) and World Bank data for 2009 were analyzed to determine the proportions of bilateral ODA from the 23 Development Assistance Committee (DAC) countries disbursed (as % of GDP in current US$) for infectious disease control. DAC country contributions to the GAVI Alliance for 2009 were assessed as a measure of multilateral donor support for vaccines and immunization programs. Findings: In 2009, total DAC bilateral ODA was 0.16% of global GDP and 0.25% of DAC GDP. As a percentage of GDP, Norway (0.013%) and United Kingdom (0.0085%) disbursed the greatest proportion of bilateral ODA for infectious disease control, and Norway (0.024%) and Canada (0.008%) made the greatest contributions to the GAVI Alliance. In 2009 0.02% of DAC GDP was US$7.61 billion and 0.02% of the GDP of the poorest 117 countries was US$2.88 billion. Conclusions: Adopting 0.02% GDP as minimum targets for both VPA and VPB is based on realistic estimates of what both developed and developing countries should spend, and can afford to spend, to jointly ensure procurement of vaccines recommended by national and global bodies. New OECD purpose codes are needed to specifically track ODA disbursed for a) vaccine procurement; and b) immunization programs.

There is strong evidence that, in addition to individual and household characteristics, social interactions are important in determining fertility rates. Social interactions can lead to a multiplier effect where an individual’s ideas, and fertility choice, can affect the fertility decisions of others. We merge all available Demographic and Health Surveys to investigate the factors that influence both individual and average group fertility. We find that in the early phase of the fertility transition the impact of a woman’s education and experience of child death on her group’s average fertility are more than three times as large as their direct effect on her own fertility decision.

In many countries worldwide, health worker shortages are one of the main constraints in achieving population health goals. Financial-incentive programmes for return of service, whereby participants receive payments in return for a commitment to practise for a period of time in a medically underserved area, can alleviate local and regional health worker shortages through a number of mechanisms. First, they can redirect the flow of those health workers who would have been educated without financial incentives from well-served to underserved areas. Second, they can add health workers to the pool of workers who would have been educated without financial incentives and place them in underserved areas. Third, financial-incentive programmes may improve the retention in underserved areas of those health workers who participate in a programme, but who would have worked in an underserved area without any financial incentives. Fourth, the programmes may increase the retention of all health workers in underserved areas by reducing the strength of some of the reasons why health workers leave such areas, including social isolation, lack of contact with colleagues, lack of support from medical specialists and heavy workload. We draw on studies of financial-incentive programmes and other initiatives with similar objectives to discuss seven management functions that are essential for the long-term success of financial-incentive programmes: financing (programmes may benefit from innovative donor financing schemes, such as endowment funds, international financing facilities or compensation payments); promotion (programmes should use tested communication channels in order to reach secondary school graduates and health workers); selection (programmes may use selection criteria to ensure programme success and to achieve supplementary policy goals); placement (programmes should match participants to areas in order to maximize participant satisfaction and retention); support (programmes should prepare participants for the time in an underserved area, stay in close contact with participants throughout the different phases of enrolment and help participants by assigning them mentors, establishing peer support systems or financing education courses relevant to work in underserved areas); enforcement (programmes may use community-based monitoring or outsource enforcement to existing institutions); and evaluation (in order to broaden the evidence on the effectiveness of financial incentives in increasing the health workforce in underserved areas, programmes in developing countries should evaluate their performance; in order to improve the strength of the evidence on the effectiveness of financial incentives, controlled experiments should be conducted where feasible). In comparison to other interventions to increase the supply of health workers to medically underserved areas, financial-incentive programmes have advantages – unlike initiatives using non-financial incentives, they establish legally enforceable commitments to work in underserved areas and, unlike compulsory service policies, they will not be opposed by health workers – as well as disadvantages – unlike initiatives using non-financial incentives, they may not improve the working and living conditions in underserved areas (which are important determinants of health workers' long-term retention) and, unlike compulsory service policies, they cannot guarantee that they will supply health workers to underserved areas who would not have worked in such areas without financial incentives. Financial incentives, non-financial incentives, and compulsory service are not mutually exclusive and may positively affect each other's performance.

Background: In many geographic regions, both in developing and in developed countries, the number of health workers is insufficient to achieve population health goals. Financial incentives for return of service are intended to alleviate health worker shortages: A (future) health worker enters into a contract to work for a number of years in an underserved area in exchange for a financial pay-off. Methods: We carried out systematic literature searches of PubMed, the Excerpta Medica database, the Cumulative Index to Nursing and Allied Health Literature, and the National Health Services Economic Evaluation Database for studies evaluating outcomes of financial-incentive programs published up to February 2009. To identify articles for review, we combined three search themes (health workers or students, underserved areas, and financial incentives). In the initial search, we identified 10,495 unique articles, 10,302 of which were excluded based on their titles or abstracts. We conducted full-text reviews of the remaining 193 articles and of 26 additional articles identified in reference lists or by colleagues. Forty-three articles were included in the final review. We extracted from these articles information on the financial-incentive programs (name, location, period of operation, objectives, target groups, definition of underserved area, financial incentives and obligation) and information on the individual studies (authors, publication dates, types of study outcomes, study design, sample criteria and sample size, data sources, outcome measures and study findings, conclusions, and methodological limitations). We reviewed program results (descriptions of recruitment, retention, and participant satisfaction), program effects (effectiveness in influencing health workers to provide care, to remain, and to be satisfied with work and personal life in underserved areas), and program impacts (effectiveness in influencing health systems and health outcomes). Results: Of the 43 reviewed studies 34 investigated financial-incentive programs in the US. The remaining studies evaluated programs in Japan (five studies), Canada (two), New Zealand (one) and South Africa (one). The programs started between 1930 and 1998. We identified five different types of programs (service-requiring scholarships, educational loans with service requirements, service-option educational loans, loan repayment programs, and direct financial incentives). Financial incentives to serve for one year in an underserved area ranged from year-2000 United States dollars 1,358 to 28,470. All reviewed studies were observational. The random-effects estimate of the pooled proportion of all eligible program participants who had either fulfilled their obligation or were fulfilling it at the time of the study was 71% (95% confidence interval 60–80%). Seven studies compared retention in the same (underserved) area between program participants and non-participants. Six studies found that participants were less likely than non-participants to remain in the same area (five studies reported the difference to be statistically significant, while one study did not report a significance level); one study did not find a significant difference in retention in the same area. Thirteen studies compared provision of care or retention in any underserved area between participants and non-participants. Eleven studies found that participants were more likely to (continue to) practice in any underserved area (nine studies reported the difference to be statistically significant, while two studies did not provide the results of a significance test); two studies found that program participants were significantly less likely than non-participants to remain in any underserved area. Seven studies investigated the satisfaction of participants with their work and personal lives in underserved areas. Conclusion: Financial-incentive programs for return of service are one of the few health policy interventions intended to improve the distribution of human resources for health on which substantial evidence exists. However, the majority of studies are from the US, and only one study reports findings from a developing country, limiting generalizability. The existing studies show that financial-incentive programs have placed substantial numbers of health workers in underserved areas and that program participants are more likely than non-participants to work in underserved areas in the long run, even though they are less likely to remain at the site of original placement. As none of the existing studies can fully rule out that the observed differences between participants and non-participants are due to selection effects, the evidence to date does not allow the inference that the programs have caused increases in the supply of health workers to underserved areas.

Shortages of human resources for treating HIV/AIDS (HRHA) are a fundamental barrier to reaching universal antiretroviral treatment (ART) coverage in developing countries. Previous studies suggest that recruiting HRHA to attain universal ART coverage poses an insurmountable challenge as ART significantly increases survival among HIV-infected individuals. While new evidence about ART’s prevention benefits suggests fewer infections may mitigate the challenge, new policies such as treatment-as-prevention (TasP) will exacerbate it. We develop a mathematical model to analytically study the net effects of these countervailing factors. Using South Africa as a case study, we find that contrary to previous results, universal ART coverage is achievable even with current HRHA numbers. However, larger health gains are possible through a surge-capacity policy that aggressively recruits HRHA to reach universal ART coverage quickly. Without such a policy, TasP roll-out can increase health losses by crowding out sicker patients from treatment, unless a surge capacity exclusively for TasP is also created.

We analyze the effect of fertility on income per capita with a particular focus on the experience of Europe. For European countries with below-replacement fertility, the cost of continued low fertility will only be observed in the long run. We show that in the short run, a fall in the fertility rate will lower the youth dependency ratio and increase the working-age share, thus raising income per capita. In the long run, however, the burden of old-age dependency dominates the youth dependency decline, and continued low fertility will lead to small working-age shares in the absence of large migration inflows. We show that the currently very high working-age shares generated by the recent declines in fertility and migration inflows are not sustainable, and that significant drops in the relative size of the working-age population should be expected. Without substantial adjustments in labor force participation or migration policies, the potential negative repercussions on the European economy are large.

Background: Globally, the status of women’s health falls short of its potential. In addition to the deleterious ethical and human rights implications of this deficit, the negative economic impact may also be consequential, but these mechanisms are poorly understood. Building on the literature that highlights health as a driver of economic growth and poverty alleviation, we aim to systematically investigate the broader economic benefits of investing in women’s health. Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we systematically reviewed health, gender, and economic literature to identify studies that investigate the impact of women’s health on micro- and macroeconomic outcomes. We developed an extensive search algorithm and conducted searches using 10 unique databases spanning the timeframe 01/01/1970 to 01/04/2013. Articles were included if they reported on economic impacts stemming from changes in women’s health (table of outcome measures included in full review, Table 1). In total, the two lead investigators independently screened 20,832 abstracts and extracted 438 records for full text review. The final review reflects the inclusion of 124 articles. Results: The existing literature indicates that healthier women and their children contribute to more productive and better-educated societies. This study documents an extensive literature confirming that women’s health is tied to long-term productivity: the development and economic performance of nations depends, in part, upon how each country protects and promotes the health of women. Providing opportunities for deliberate family planning; healthy mothers before, during, and after childbirth, and the health and productivity of subsequent generations can catalyze a cycle of positive societal development. Conclusions: This review highlights the untapped potential of initiatives that aim to address women’s health. Societies that prioritize women’s health will likely have better population health overall, and will remain more productive for generations to come.