Comparison Districts Research Articles

Effectiveness of peer-supervision on pediatric fever illness treatment among registered private drug sellers in East-Central Uganda: An interrupted time series analysis.

Rationale, aims, and objectivesAppropriate treatment of pediatric fever in rural areas remains a challenge and maybe partly due to inadequate supervision of licensed drug sellers. This study assessed the effectiveness of peer‐supervision among drug sellers on the appropriate treatment of pneumonia symptoms, uncomplicated malaria, and non‐bloody diarrhea among children less than 5 years of age in the intervention (Luuka) and comparison (Buyende) districts, in East‐Central Uganda.MethodsData on pneumonia symptoms, uncomplicated malaria, and non‐bloody diarrhea among children less than 5 years of age was abstracted from drug shop sick child registers over a 12‐month period; 6 months before and 6 months after the introduction of peer‐supervision. Interrupted time series were applied to determine the effectiveness of the peer‐supervision intervention on the appropriate treatment of pneumonia, uncomplicated malaria, and non‐bloody diarrhea among children less than 5 years of age attending drug shops in East Central Uganda.ResultsThe proportion of children treated appropriately for pneumonia symptoms was 10.84% (P < .05, CI = [1.75, 19.9]) higher, for uncomplicated malaria was 1.46% (P = .79, CI = [−10.43, 13.36]) higher, and for non‐bloody diarrhea was 4.00% (P < .05, CI = [−7.95, −0.13]) lower in the intervention district than the comparison district, respectively.Post‐intervention trend results showed an increase of 1.21% (P = .008, CI = [0.36, 2.05]) in the proportion appropriately treated for pneumonia symptoms, no difference in appropriate treatment for uncomplicated malaria, and a reduction of 1% (P < .06, CI = [−1.95, 0.02]) in the proportion of children appropriately treated for non‐bloody diarrhea, respectively.ConclusionsPeer‐supervision increased the proportion of children less than 5 years of age that received appropriate treatment for pneumonia symptoms but not for uncomplicated malaria and non‐bloody diarrhea. Implementation of community‐level interventions to improve pediatric fever management should consider including peer‐supervision among drug sellers.

User fees removal and community-based management of undernutrition in Burkina Faso: what effects on children's nutritional status?

To examine the effect of an intervention combining user fees removal with community-based management of undernutrition on the nutrition status in children under 5 years of age in Burkina Faso. The study was a non-equivalent control group post-test-only design based on household survey data collected 4 years after the intervention onset in the intervention and comparison districts. Additionally, we used propensity score weighting to achieve balance on covariates between the two districts, followed by logistic multilevel modelling. Two health districts in the Sahel region. Totally, 1116 children under 5 years of age residing in 41 intervention communities and 1305 from 51 control communities. When comparing children living in the intervention district to children living in a non-intervention district, we determined no differences in terms of stunting (OR = 1·13; 95 % CI 0·83, 1·54) and wasting (OR = 1·21; 95 % CI 0·90, 1·64), nor in severely wasted (OR = 1·27; 95 % CI 0·79, 2·04) and severely stunted (OR = 0·99; 95 % CI 0·76, 1·26). However, we determined that 3 % of the variance of wasting (95 % CI 1·25, 10·42) and 9·4 % of the variance of stunting (95 % CI 6·45, 13·38) were due to systematic differences between communities of residence. The presence of the intervention in the communities explained 2 % of the community-level variance of stunting and 3 % of the community-level variance of wasting. With the scaling-up of the national free health policy in Africa, we stress the need for rigorous evaluations and the means to measure expected changes in order to better inform health interventions.

Effect of nutrition behaviour change communication delivered through radio on mothers' nutritional knowledge, child feeding practices and growth.

Childhood undernutrition coupled with poor feeding practices continues to be public health problems in many parts of the world and efforts to address them remain elusive. We tested the hypothesis that women who are exposed to radio health/nutrition education will demonstrate greater nutrition and health knowledge, positive attitudes towards preventive health and better dietary diversity practices for improved child growth. We used a two-arm, quasi-experimental, non-equivalent comparison group design with pre- and post-test observations to evaluate the intervention. The study population comprised 712 mothers with children aged 6-36 months who were randomly selected from five intervention districts and one comparison district in Northern Ghana. Difference-in-difference (DID) analysis was performed to assess study outcomes. After 12-month implementation of intervention activities, the minimum dietary diversity and the minimum acceptable diet improved significantly (DID 9⋅7 percentage points, P 0⋅014 and DID 12⋅1 percentage points, P 0⋅001, respectively) in the intervention study group, compared with the comparison group. Mothers in the intervention communities had a nutrition-related knowledge, attitudes and practices score that was significantly higher than their colleagues in the comparison communities (DID 0⋅646, P < 0⋅001). The intervention did not have significant effects on the nutritional status as measured by height-for-age Z-score or weight-for-height Z-score. The data provide evidence that health and nutrition education using radio drama significantly increased health-/nutrition-related knowledge but had little effect on nutritional status.

Construction and demolition wastes in Beijing: Where they come from and where they go?

Urbanization and related construction activities generate massive construction and demolition (C&D) waste, which poses considerable risks to the environment and human health. However, it is difficult to assess the significance of these issues without a quantitative understanding of spatial patterns of C&D waste generation (source), transportation (flow), and treatment (sink). This paper maps source, sinks, and flows of C&D waste by coupling a geographic information system and material flow analysis. The methodology is new in the field of C&D waste quantification at the city level, especially downscaling to 5 km × 5 km grids. The results showed that a total of 37.72 million metric tonnes (Mt) of C&D wastes were generated in Beijing, 2019, and ~72% of them were reused and recycled. In space, C&D waste generation in suburban and rural districts (28.73 Mt) was over three times more than that in the downtown area (8.99 Mt). However, the downtown area was the net source region and transported massive amounts of C&D waste to suburban and rural districts. In comparison, several suburban and rural districts had self-sufficient treatment capacity. Our study highlights that a series of C&D waste maps on multiple spatial scales are of great help to design effective policies for waste management by providing spatial details of magnitude and components, and explicitly recognizing primary source and sink areas in cities.

Impact of the Ananya program on reproductive, maternal, newborn and child health and nutrition in Bihar, India: early results from a quasi-experimental study

Background The Government of Bihar (GoB) in India, the Bill and Melinda Gates Foundation and several non-governmental organisations launched the Ananya program aimed to support the GoB to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) statewide. Here we summarise changes in indicators attained during the initial two-year pilot phase (2012-2013) of implementation in eight focus districts of approximately 28 million population, aimed to inform subsequent scale-up. Methods The quasi-experimental impact evaluation included statewide household surveys at two time points during the pilot phase: January-April 2012 ("baseline") including an initial cohort of beneficiaries and January-April 2014 ("midline") with a new cohort. The two arms were: 1) eight intervention districts, and 2) a comparison arm comprised of the remaining 30 districts in Bihar where Ananya interventions were not implemented. We analysed changes in indicators across the RMNCHN continuum of care from baseline to midline in intervention and comparison districts using a difference-in-difference analysis. Results Indicators in the two arms were similar at baseline. Overall, 40% of indicators (20 of 51) changed significantly from baseline to midline in the comparison districts unrelated to Ananya; two-thirds (n = 13) of secular indicator changes were in a direction expected to promote health. Statistically significant impact attributable to the Ananya program was found for 10% (five of 51) of RMNCHN indicators. Positive impacts were most prominent for mother's behaviours in contraceptive utilisation. Conclusions The Ananya program had limited impact in improving health-related outcomes during the first two-year period covered by this evaluation. The program's theories of change and action were not powered to observe statistically significant differences in RMNCHN indicators within two years, but rather aimed to help inform program improvements and scale-up. Evaluation of large-scale programs such as Ananya using theory-informed, equity-sensitive (including gender), mixed-methods approaches can help elucidate causality and better explain pathways through which supply- and demand-side interventions contribute to changes in behaviour among the actors involved in the production of population-level health outcomes. Evidence from Bihar indicates that deep structural constraints in health system organisation and delivery of interventions pose substantial limitations on behaviour change among health care providers and beneficiaries. Study registration ClinicalTrials.gov number NCT02726230.

Impact Evaluation of a Comprehensive Nutrition Program for Reducing Stunting in Children Aged 6–23 Months in Rural Malawi

The prevalence of stunting in central rural Malawi is ∼50%, which prompted a multipronged nutrition program in 1 district from 2014 to 2016. The program distributed a daily, fortified, small-quantity lipid-based nutritional supplement, providing 110kcal and 2.6g of protein to children aged 6-23mo, and behavior change messages around optimal infant and young child feeding (IYCF) and water, sanitation, and hygiene. Our objective was to perform an impact evaluation of the program using a neighboring district as comparison. Using a quasi-experimental study design, with cross-sectional baseline (January-March, 2014; n=2404) and endline (January-March, 2017; n=2453) surveys, we evaluated the program's impact using a neighboring district as comparison. Impact on stunting was estimated using propensity score weighted difference-in-differences regression analyses to account for baseline differences between districts. No differences in mean length-for-age z-score or prevalence of stunting were found at endline. However, mean weight, weight-for-length z-score, and mid-upper arm circumference were higher at endline by 150g, 0.22, and 0.19cm, respectively, in the program compared with the comparison district (all P<0.05). Weekly reports of high fever and malaria were also lower by 6.4 and 4.7 percentage points, respectively, in the program compared with the comparison district (both P<0.05). There was no impact on anemia. Children's dietary diversity score improved by 0.17, and caregivers' infant and young child feeding and hand-washing practices improved by 8-11% in the program compared with the comparison district (all P<0.05). An impact evaluation of a comprehensive nutrition program in rural Malawi demonstrated benefit for child ponderal growth and health, improved maternal IYCF and hand-washing practices, but a reduction in stunting prevalence was not observed.

Effects of the Helping Mothers Survive Bleeding after Birth training on near miss morbidity and mortality in Uganda: A cluster-randomized trial.

ObjectiveTo assess the effect of Helping Mothers Survive Bleeding after Birth training on postpartum hemorrhage (PPH) near miss and case fatality rates in Uganda.MethodsTraining was evaluated using a cluster‐randomized design between June 2016 and September 2017 in 18 typical rural districts (clusters) in Eastern and Central Uganda of which nine districts were randomly assigned to the intervention. The main outcome was PPH near miss defined using the World Health Organization’s disease and management‐based approach. Interrupted time series analysis was performed to estimate the difference in the change of outcomes.ResultsOutcomes of 58 000 and 95 455 deliveries during the 6‐month baseline and 10‐month endline periods, respectively, were included. A reduction of PPH near misses was observed in the intervention compared to the comparison districts (difference‐in‐difference of slopes 4.19, 95% CI, –7.64 to –0.74); P<0.05). There was an increase in overall reported near miss cases (difference‐in‐difference 1.24, 95% CI, 0.37–2.10; P<0.001) and an increase in PPH case fatality rate (difference‐in‐difference 2.13, 95% CI, 0.14–4.12; P<0.05).ConclusionThis pragmatic cluster‐randomized trial conducted in typical rural districts of Uganda indicated a reduction of severe PPH cases while case fatality did not improve, suggesting that this basic training needs to be complemented by additional measures for sustained mortality reduction. Trial registration: PACTR201604001582128.

Achieving the Sustainable Development Goals for water and sanitation in Indonesia - Results from a five-year (2013-2017) large-scale effectiveness evaluation.

BackgroundAccess to safe sanitation and the elimination of open defecation are pre-conditions for improved child health and nutrition and wider achievement of the Sustainable Development Goals (SDGs). While Indonesia has a solid policy framework, the country ranks third globally in terms of numbers of people practicing open defecation.ObjectivesOur aim was to assess the effectiveness of a five-year strategy to reduce open defecation through accelerating implementation of the national sanitation program across districts receiving variable levels of external support.MethodsAmong three provinces with poor sanitation program performance, districts were selected to receive one of three levels of external support. High intensity districts (n = 6) benefitted from enabling environment strengthening support including political and social mobilization, direct capacity development, and efforts to strengthen planning, budgeting, monitoring and supervision; learning districts (n = 16) benefitted from cross-district learning opportunities and political mobilization through provincial government advocacy efforts; and comparison districts (n = 58) were monitored under routine program conditions. Outcomes included open defecation free (ODF) status and new toilet facility construction and were assessed through village level monitoring systems across all districts. Negative binomial regression and multivariate analysis were used to assess associations between levels of intervention intensity and outcomes.FindingsAmong districts receiving high-intensity external support improvements in political commitment, planning, coordination, financing, monitoring and supervision were observed. Relative to comparison districts, high intensity districts were more likely to be ODF (aRR 4.65, CI 2.12–10.20) with greater increase in household toilet coverage (aRR 11.15 CI 1.04–119.82). Weaker non-significant associations with ODF were observed among learning districts relative to comparison districts.InterpretationEfforts to strengthen provincial and district government capacity to implement sanitation programming in Indonesia can yield substantial improvements in outcomes in a relatively short period of time.

Evaluation of a city-wide school-located influenza vaccination program in Oakland, California, with respect to vaccination coverage, school absences, and laboratory-confirmed influenza: A matched cohort study.

It is estimated that vaccinating 50%-70% of school-aged children for influenza can produce population-wide indirect effects. We evaluated a city-wide school-located influenza vaccination (SLIV) intervention that aimed to increase influenza vaccination coverage. The intervention was implemented in ≥95 preschools and elementary schools in northern California from 2014 to 2018. Using a matched cohort design, we estimated intervention impacts on student influenza vaccination coverage, school absenteeism, and community-wide indirect effects on laboratory-confirmed influenza hospitalizations. We used a multivariate matching algorithm to identify a nearby comparison school district with pre-intervention characteristics similar to those of the intervention school district and matched schools in each district. To measure student influenza vaccination, we conducted cross-sectional surveys of student caregivers in 22 school pairs (2017 survey, N = 6,070; 2018 survey, N = 6,507). We estimated the incidence of laboratory-confirmed influenza hospitalization from 2011 to 2018 using surveillance data from school district zip codes. We analyzed student absenteeism data from 2011 to 2018 from each district (N = 42,487,816 student-days). To account for pre-intervention differences between districts, we estimated difference-in-differences (DID) in influenza hospitalization incidence and absenteeism rates using generalized linear and log-linear models with a population offset for incidence outcomes. Prior to the SLIV intervention, the median household income was $51,849 in the intervention site and $61,596 in the comparison site. The population in each site was predominately white (41% in the intervention site, 48% in the comparison site) and/or of Hispanic or Latino ethnicity (26% in the intervention site, 33% in the comparison site). The number of students vaccinated by the SLIV intervention ranged from 7,502 to 10,106 (22%-28% of eligible students) each year. During the intervention, influenza vaccination coverage among elementary students was 53%-66% in the comparison district. Coverage was similar between the intervention and comparison districts in influenza seasons 2014-2015 and 2015-2016 and was significantly higher in the intervention site in seasons 2016-2017 (7%; 95% CI 4, 11; p < 0.001) and 2017-2018 (11%; 95% CI 7, 15; p < 0.001). During seasons when vaccination coverage was higher among intervention schools and the vaccine was moderately effective, there was evidence of statistically significant indirect effects: The DID in the incidence of influenza hospitalization per 100,000 in the intervention versus comparison site was -17 (95% CI -30, -4; p = 0.008) in 2016-2017 and -37 (95% CI -54, -19; p < 0.001) in 2017-2018 among non-elementary-school-aged individuals and -73 (95% CI -147, 1; p = 0.054) in 2016-2017 and -160 (95% CI -267, -53; p = 0.004) in 2017-2018 among adults 65 years or older. The DID in illness-related school absences per 100 school days during the influenza season was -0.63 (95% CI -1.14, -0.13; p = 0.014) in 2016-2017 and -0.80 (95% CI -1.28, -0.31; p = 0.001) in 2017-2018. Limitations of this study include the use of an observational design, which may be subject to unmeasured confounding, and caregiver-reported vaccination status, which is subject to poor recall and low response rates. A city-wide SLIV intervention in a large, diverse urban population was associated with a decrease in the incidence of laboratory-confirmed influenza hospitalization in all age groups and a decrease in illness-specific school absence rate among students in 2016-2017 and 2017-2018, seasons when the vaccine was moderately effective, suggesting that the intervention produced indirect effects. Our findings suggest that in populations with moderately high background levels of influenza vaccination coverage, SLIV programs are associated with further increases in coverage and reduced influenza across the community.

Determinants of healthcare providers\u2019 confidence in their clinical skills to deliver quality obstetric and newborn care in Uganda and Zambia

BackgroundPoor quality obstetric and newborn care persists in sub-Saharan Africa and weak provider competence is an important contributor. To be competent, providers need to be both knowledgeable and confident in their ability to perform necessary clinical actions. Confidence or self-efficacy has not been extensively studied but may be related to individuals’ knowledge, ability to practice their skills, and other modifiable factors. In this study, we investigated how knowledge and scope of practice are associated with provider confidence in delivering obstetric and newborn health services in Uganda and Zambia.MethodsThis study was a secondary analysis of data from an obstetric and newborn care program implementation evaluation. Provider knowledge, scope of practice (completion of a series of obstetric tasks in the past 3 months) and confidence in delivering obstetric and newborn care were measured post intervention in intervention and comparison districts in Uganda and Zambia. We used multiple linear regression models to investigate the extent to which exposure to a wider range of clinical tasks associated with confidence, adjusting for facility and provider characteristics.ResultsOf the 574 providers included in the study, 69% were female, 24% were nurses, and 6% were doctors. The mean confidence score was 71%. Providers’ mean knowledge score was 56% and they reported performing 57% of basic obstetric tasks in the past 3 months. In the adjusted model, providers who completed more than 69% of the obstetric tasks reported a 13-percentage point (95% CI 0.08, 0.17) higher confidence than providers who performed less than 50% of the tasks. Female providers and nurses were considerably less confident than males and doctors. Provider knowledge was moderately associated with provider confidence.ConclusionsOur study showed that scope of practice (the range of clinical tasks routinely performed by providers) is an important determinant of confidence. Ensuring that providers are exposed to a variety of services is crucial to support improvement in provider confidence and competence. Policies to improve provider confidence and pre-service training should also address differences by gender and by cadres.

Double Fortified Salt Delivered Through the Public Distribution System Reduced Risk of Iron Deficiency but Not of Anemia or Iron Deficiency Anemia in Uttar Pradesh, India

Abstract Objectives Double fortified salt (DFS) with iodine and iron is efficacious in improving anemia, but evidence of effectiveness in large-scale programs is limited. We evaluated a program delivering double fortified salt (DFS) over 12 mo in five districts through the public distribution system in Uttar Pradesh, India on iron status and anemia. Methods Only two (Etawah and Auraiya) of the five intervention districts met the evaluability threshold of 50% DFS utilization chosen as an a priori criterion for endline inclusion. We present findings on cross-sectional survey data collected from 6388 non-pregnant women of reproductive age (WRA) in Etawah and Auraiya, and their two matched adjacent boundary comparison districts. We used generalized linear models that accounted for clustering, with log link function for risk ratio (RR) and identity link function for mean difference, adjusting for matched pairs. Models were adjusted for WRA age, education of WRA and household head, religion and housing. Ferritin levels were inflammation adjusted using the BRINDA regression equation. Results There was no difference in anemia and iron deficiency anemia (IDA) prevalence or in mean hemoglobin concentration between WRA in intervention and comparison districts. However, we observed a 15% lower risk of being iron deficient in intervention areas (RR = 0.85: 95% CI, 0.75–0.98). Additionally, WRA in intervention districts who reported regular use of DFS had 23% lower risk of being iron deficient (RR = 0.77: 95% CI, 0.66–0.93), and those reporting partial use had 20% lower risk (RR = 0.80: 95% CI, 0.66–0.99). There was no difference among non-users (RR = 0.98: 95% CI, 0.88–1.22). Conclusions DFS was effective in reducing risk of iron deficiency, but not anemia or IDA, among WRA. This modest effectiveness may have been in part due to supply chain interruptions over the course of the implementation period (slow start and earlier than planned cessation). We observed a dose responsive effect, with greater risk reductions among regular and partial users than among non-users. To maximize this potential and perhaps extend impacts to anemia or IDA, the program will require: 1) longer duration of exposure, 2) investments in addressing barriers to coverage and utilization, and 3) complementary efforts to address other causes of anemia in this context. Funding Sources Bill &amp; Melinda Gates Foundation.

Understanding efficiency and the effect of pay-for-performance across health facilities in Tanzania

BackgroundEnsuring efficient use and allocation of limited resources is crucial to achieving the UHC goal. Performance-based financing that provides financial incentives for health providers reaching predefined targets would be expected...

Does expanding community-based primary health care coverage also address unmet need for family planning and improve program impact? Findings from a plausibility trial in northern Ghana

Background The core strategy for achieving universal health coverage (UHC) in Ghana concerns the goal of expanding access to primary health services to all rural households through an initiative known as Community-based Health Planning and Services (CHPS). To test means of accelerating CHPS implementation, a 5-year primary health system strengthening trial was launched in 2010 that was known as the Ghana Essential Health Interventions Program (GEHIP). Fielded in 4 rural northern districts with 7 comparison districts, GEHIP achieved total CHPS coverage in 4 years, thereby expanding access to community nursing care for the treatment of childhood illness, the provision of immunizations, and promotion and delivery of family planning services. Methods The impact of UHC achievement on contraceptive use and unmet need is assessed with a 2 stage random sample of reproductive-aged women residing in treatment and comparison districts at the GEHIP baseline and end line. A difference-in-differences (DIDs) regression model is employed to estimate the average GEHIP treatment effect on the use of modern contraceptives and unmet need for contraception. Results After controlling for maternal age, children ever born, education, religion, ethnicity, and occupation, regression results show that the GEHIP program had a significant DID effect on modern contraceptive use (odds ratio [OR],1.795; 95% confidence interval, 1.320–2.439) but no effect on unmet need for contraception. Conclusion Expanding access to community-based primary health care improved contraceptive use, but was insufficient for reducing unmet need. Possible implications for supplementing community-based primary health care with family planning focused social mobilization are reviewed.

The START study: An evaluation to study the impact of a natural experiment in high school start times on adolescent weight and related behaviors

Research has shown that early high school start times, which are asynchronous with adolescent biology, are one of the most significant obstacles to youth being able to net sufficient sleep. Given that adolescence is a critical period that sets the stage for long-term obesity risk behavior patterns, there is an need to understand the obesity-related implications of increased sleep as a result of intervention and policy changes. We evaluated a community-based natural experiment in school start time policy modification when several Minneapolis-St. Paul, MN metro area school districts shifted to later school start times in Fall 2016. We collected data on student weight and related risks (via paper survey, objective weight and height measurement, dietary recall, and sleep actigraphy) before and after two districts (two high schools) shifted their start times later and in a comparison district (three high schools) which kept their start times early (7:30am) through the course of the study. Our specific aims were: 1) Determine how a shift to a later high school start time relates to objectively measured weight change over time. 2) Identify the relationship between school start times and obesity-related behaviors over time.At baseline we had 2,133 returned surveys (93% participation) and 2,037 (86% participation) objective height/weight measurements from 9th grade students (class of 2019) in the five schools. The sample was 87.7% white, 12.8% reported qualifying for free/reduced price lunch (a measure of lower socio-economic status), and the mean age was 15.2 (SD=0.35) years. The products of this research will clarify causal connections between sleep and obesity among adolescents as well as provide evidence for whether a school start time policy can minimize unhealthy weight gain.

Household Food Security Status of Families with Children Attending Schools that Participate in the Community Eligibility Provision (CEP) and Those with Children Attending Schools that are CEP-Eligible, but Not Participating

ABSTRACT This study examined the association of household food security and school participation in the community eligibility provision (CEP). Surveys were collected from 427 households within 5 schools participating in CEP, and therefore providing access to universal free school meals, and three matched comparison district schools, which were CEP-eligible but not participating. Multivariate logistic regression, adjusted for race/ethnicity and education level, revealed that the odds of being in a food insecure household were twice as likely for students attending CEP-eligible, but not participating schools than for students attending CEP schools [OR 2.85 (95% CI 1.67, 4.88)].

ANALISIS PENERIMAAN BEA PEROLEHAN HAK ATAS TANAH DAN BANGUNAN (BPHTB) DI KABUPATEN BANJAR

Helda Yuliana, (2018), “Analysis of The Tax Revenue Fees For Acqiusition of Land and Buildings (BPHTB) in Banjar District”. The transfer of management of Tax for Acquisition of Land and Buildings (BPHTB) and Land and Building Tax–Urban and Rural(PBB-P2) from the central government to regional government is a follow up of regional autonomy and fiscal decentralization policy. With the transfer ofBPHTB inti local taxes, BPHTB took part in contributing tothe District Own Source Revenue(PAD). Thepurpose of this research are to knows how much thecontribution, how effectiveness and efficiency, how BPHTB potency, what are the obstacles in BPHTB collection, and what strategy needs to be done to increase BPHTB revenue. The type of the research isa descriptive method. The data sourece used is secondary data obtained from Bapenda Banjar district to calculate the contribution, effectiveness and efficiency, and primary data obtained from interviews to know the potential, constraints, and strategies in the revenue of BPHTB. The results ofthis research can be concluded that contribution of BPHTB to local revenue (PAD) still deficient. The effectiveness of 2012-2016 is very effective because the effectiveness is always above 100% and the implementation of BPHTB collection is ver efficient. BPHTB of Banjar district has a very high potential and potentially will continue to increase. Obstacles faced by Banjar distict government that is not yet applied marketprice and still only refers to NJOP. Strategy that can be done is by using price comparison and Banjar district government routinely conduct evaluation meeting with BPN and notary/PPAT.Keywords: BPHTB, PAD, contribution,effectiveness, efficiency, potency

Health visitors' competences before and after implementing the newborn behavioral observations (NBO) system in a community setting: A cluster randomised study.

To explore differences between health visitors' competences before and after implementing the newborn behavioral observations (NBO) system in four Danish municipalities. In a cluster randomized design, 56 and 55 health visitors were enrolled in the intervention and comparison districts. Only health visitors from the intervention district received the NBO education programme. Data from self-administered questionnaires on heath visitors' intention, self-efficacy, knowledge, and observation skills were collected before and after NBO training. Data were analysed using descriptive and multivariable analyses. Health visitors reported high levels of intention, self-efficacy, and knowledge working with early parent-infant relationships in both groups at baseline. After implementing NBO, the intervention health visitors reported a significantly higher level of knowledge of infant self-regulation than the comparison group. No significant differences were found in health visitors' level of intention and self-efficacy working with early parent-infant relationships, or in health visitors' observation skills assessing the quality of early relationship. Health visitors attending the NBO education and working with NBO in clinical practise had a significantly higher level of knowledge of infant self-regulation. A new discussion of how to educate health visitors' competencies working with early relationship in clinical practise is needed.

The Costs and Cost-Effectiveness of a District-Strengthening Strategy to Mitigate the 3 Delays to Quality Maternal Health Care: Results From Uganda and Zambia.

The primary objective of this study was to estimate the costs and the incremental cost-effectiveness of maternal and newborn care associated with the Saving Mothers, Giving Life (SMGL) initiative-a comprehensive district-strengthening approach addressing the 3 delays associated with maternal mortality-in Uganda and Zambia. To assess effectiveness, we used a before-after design comparing facility outcome data from 2012 (before) and 2016 (after). To estimate costs, we used unit costs collected from comparison districts in 2016 coupled with data on health services utilization from 2012 in SMGL-supported districts to estimate the costs before the start of SMGL. We collected data from health facilities, ministerial health offices, and implementing partners for the year 2016 in 2 SMGL-supported districts in each country and in 3 comparison non-SMGL districts (2 in Zambia, 1 in Uganda). Incremental costs for maternal and newborn health care per SMGL-supported district in 2016 was estimated to be US$845,000 in Uganda and $760,000 in Zambia. The incremental cost per delivery was estimated to be $38 in Uganda and $95 in Zambia. For the districts included in this study, SMGL maternal and newborn health activities were associated with approximately 164 deaths averted in Uganda and 121 deaths averted in Zambia in 2016 compared to 2012. In Uganda, the cost per death averted was $10,311, or $177 per life-year gained. In Zambia, the cost per death averted was $12,514, or $206 per life-year gained. The SMGL approach can be very cost-effective, with the cost per life-year gained as a percentage of the gross domestic product (GDP) being 25.6% and 16.4% in Uganda and Zambia, respectively. In terms of affordability, the SMGL approach could be paid for by increasing health spending from 7.3% to 7.5% of GDP in Uganda and from 5.4% to 5.8% in Zambia.

Effect of the competency-based Helping Mothers Survive Bleeding after Birth (HMS BAB) training on maternal morbidity: a cluster-randomised trial in 20 districts in Tanzania

BackgroundTraining health providers is an important strategy to improve health. We conducted a cluster-randomised two-arm trial in Tanzania to assess the effect of a 1-day competency-based training ‘Helping Mothers Survive...

An Evaluation of Healthcare Use and Child Morbidity 4\xa0Years After User Fee Removal in Rural Burkina Faso

Objectives Increasing financial access to healthcare is proposed to being essential for improving child health outcomes, but the available evidence on the relationship between increased access and health remains scarce. Four years after its launch, we evaluated the contextual effect of user fee removal intervention on the probability of an illness occurring and the likelihood of using health services among children under 5. We also explored the potential effect on the inequality in healthcare access. Methods We used a comparative cross-sectional design based upon household survey data collected years after the intervention onset in one intervention and one comparison district. Propensity scores weighting was used to achieve balance on covariates between the two districts, which was followed by logistic multilevel modelling to estimate average marginal effects (AME). Results We estimated that there was not a significant difference in the reduced probability of an illness occurring in the intervention district compared to the non-intervention district [AME 4.4; 95% CI 1.0–9.8)]. However, the probability of using health services was 17.2% (95% CI 15.0–26.6) higher among children living in the intervention district relative to the comparison district, which rose to 20.7% (95% CI 9.9–31.5) for severe illness episodes. We detected no significant differences in the probability of health services use according to socio-economic status [χ2 (5) = 12.90, p = 0.61]. Conclusions for Practice In our study, we found that user fee removal led to a significant increase in the use of health services in the longer term, but it is not adequate by itself to reduce the risk of illness occurrence and socioeconomic inequities in the use of health services.