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Te intervention package stantially and rapidly reduce maternal deaths in averted an estimated 74% (95% CI: 55–99%) of order that the MDG target is achieved? Emergency obstetric complications and interventions classifed as severe acute maternal morbidity (SAMM) discount 100 mg caverta with amex, Kabezi purchase caverta 100mg overnight delivery, Burundi buy 50mg caverta amex, 2011 Emergency No (%) Total 765 (100) Prolonged/obstructed labour requiring caesarean section or instrumental delivery 267 (35) Complicated abortion (spontaneous or induced) 226 (30) Prepartum or postpartum haemorrhage 91 (12) Caesarean section due to excessively elevated uterus or abnormal presentation of the baby requiring 73 (10) caesarean section Dead baby in utero with uterine contractions > 48 hours 46 (6) Pre-eclampsia 18 (2) Sepsis 15 (2) Uterine rupture 14 (2) Ectopic pregnancy 5 (0 cheap caverta 100mg overnight delivery. However buy discount caverta 50 mg line, standard 400 case defnitions for SAMM were available and 275 clinicians were well trained in their use, and this 200 208 should have limited any error in estimates. Tis is one way of making progress towards universal health coverage, and MDG, Millennium Development Goal. Te challenge Reproduced, by permission of the publisher, from ahead is to ensure that funds and other resources Tayler-Smith et al. Further research is 78 Chapter 3 How research contributes to universal health coverage needed on cost–efectiveness and how to adapt health outcomes, particularly for poorer popu- such interventions to diferent settings. Studies from Brazil, Colombia, Honduras, Main conclusions Malawi, Mexico and Nicaragua were included. With regard to other health out- improve the use of health services comes, mothers reported a 20–25% decrease in the probability of children under three years of and health outcomes: a systematic age being ill in the previous month. Schoolgirls and young women aged ments to households on the condition that they 13–22 years were randomly allocated monthly comply with certain predetermined require- cash payments or nothing at all. Tose receiv- ments in relation to health care or other social ing monthly cash payments were further subdi- programmes (Fig. CCT programmes have vided into two groups: those who received the been justifed on the basis that providing sub- payments conditionally (on attending school sidies is necessary to encourage the use of and for 80% of the days that the school was in ses- access to health services by poor people (64). Households received varied amounts of and to increase the demand for and utilization of US$ 4–10 and the amount given to the girl varied health services by reducing or eliminating fnan- in the range US$ 1–5. What is the evidence that enrolled, HIV prevalence 18 months afer enrol- such an approach works? Te prevalence of herpes simplex A systematic review assessed the available evi- virus type 2 (HSV-2) was 0. Tere were no 79 Research for universal health coverage Fig. Identity cards are an integral part of schemes that provide conditional cash transfers in health and education programmes diferences between the conditional and uncon- in the under-fves. In addition, the programme ditional cash transfer groups in HIV or HSV-2 was shown to increase vaccination coverage and prevalence. Tese fndings show that fnancially prenatal visits by mothers and to reduce hospi- empowering schoolgirls might have a benefcial talization rates in the under-fves (66). In Brazil, a country-wide ecological study Towards universal health coverage showed that increased coverage of the Bolsa There is now a substantial body of data show- Familia programme, a national CCT programme ing that CCTs can, under some circumstances, transferring cash to poor households if they have positive effects on nutritional status and comply with conditions related to health and health by increasing the use of health services education, was signifcantly associated with the and by promoting healthy behaviours (13, 67– reduction of mortality (whether from all causes 69). However, CCT schemes do not necessarily or from poverty-related causes) in children work everywhere. Te efect of consolidated variety of factors, such as being able to identify Bolsa Familia coverage was highest on mortal- participating individuals with unique person ity resulting from malnutrition and diarrhoea identifiers (Fig. Te 2003 Mexican health reform legislated There are also limitations to the studies that the System of Social Protection in Health, of have been carried out to date. It is clearly important the frst few years of Seguro Popular, and taking to find the right mix of incentives and regula- advantage of its phased roll-out, it was important tions that affect both the supply of and demand to assess the impact of the intervention on health for services so that CCTs can improve the qual- and fnancial expenditure (70). Study design In a cluster randomized study, 100 pairs of health Main conclusions facility catchment areas (“health clusters”) were ■ CCT schemes serve as fnancial incentives randomly assigned to receive either the inter- for increasing the demand for and utili- vention or the control. Te intervention, Seguro zation of health services by reducing or Popular, provided a package of benefts that eliminating fnancial barriers to access. Tere were also service utilization which leads to improved funds to cover catastrophic health expenditures health outcomes. In health clus- ters receiving the intervention, there was a cam- paign to persuade every family to enrol in Seguro Case-study 11 Popular. In the matched control cluster families received the usual health care which they had Insurance in the provision to pay for (14). Te main outcomes were details of accessible and afordable of expenditures which were classifed as out-of- pocket expenditures for all health services, while health services: a randomized catastrophic expenditures were defned as health controlled trial in Mexico spending greater than 30% of capacity to pay (measured in terms of income). The need for research In 2003, Mexico initiated a new set of health Summary of fndings reforms which aimed to provide health coverage In the intervention clusters, out-of-pocket to approximately 50 million people who were expenses and catastrophic expenditures were without any form of fnancial protection for 23% lower than in the control clusters. Before 2003, the right to health care was those households within intervention clusters an employment beneft that was restricted to the that signed up toSeguro Popular(44% on average), salaried workforce. A large majority of the poor catastrophic expenditures were reduced by 59%. Surprisingly, and contrary to previous observational studies, Afordable health care in ageing there was no substantial efect of Seguro Popular populations: forecasting changes on the quality of care (such as improving access in public health expenditure to and use of medical facilities or reducing drug stock-outs) or on increasing coverage for chronic in fve European countries illness. Tese fndings might be explained by the short assessment period of 10 months (71, 72). The need for research Although these results are encouraging, further As the average age of European populations research is needed to ascertain the long-term becomes older, a larger number of people will efects of the programme.

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Increases in cardiac output – fluid loss 0 + increase arterial pressure both directly and 0 50 100 150 200 by increasing peripheral vascular resistance M AP buy 100 mg caverta with mastercard, mm Hg (autoregulation) cheap caverta 50mg without a prescription. Increased arterial pressure + – Rate of change + is sensed by the kidney discount caverta 100mg mastercard, leading to increased Arterial Kidney volume Extracellular kidney volum e output (pressure diuresis of extracellular pressure output fluid volume fluid volume and pressure natriuresis) discount caverta 100 mg with amex, and thus return- + ing the ECF volum e to norm al buy discount caverta 100 mg. The inset + shows this relation between m ean arterial Total peripheral + resistance Blood volume pressure (M AP), renal volum e, and sodium + excretion. The effects of acute increases + Autoregulation in arterial pressure on urinary excretion are + + M ean circulatory Cardiac output Venous return shown by the solid curve. The chronic filling pressure effects are shown by the dotted curve; note that the dotted line is identical to the curve in Figure 2-3. Thus, when the M AP increas- FIGURE 2-4 es, urinary output increases, leading to Schem a for the kidney blood volum e pressure feedback m echanism adapted from the decreased ECF volum e and return to the work of Guyton and colleagues. Positive relations are indicated by a plus sign; original pressure set point. UN aV— urinary inverse relations are indicated by a m inus sign. The block diagram shows that increases sodium excretion volum e. FIGURE 2-5 Lumen Blood Sodium (N a) reabsorption along the m am m alian nephron. About Na DCT 25 m oles of N a in 180 L of fluid daily is delivered into the Cl 5-7% glom erular filtrate of a norm al person. About 60% of this load is reabsorbed along the proxim al tubule (PRO X), indicated in dark blue; about 25% along the loop of H enle (LO H ), including the CD 3-5% thick ascending lim b indicated in light blue; about 5% to 7% along the distal convoluted tubule (DCT), indicated in dark gray; PROX 60% – + and 3% to 5% along the collecting duct (CD) system , indicated in Na light gray. All N a transporting cells along the nephron express the Lumen Blood ouabain-inhibitable sodium -potassium adenosine triphosphatase Lumen H O Blood K (N a-K ATPase) pum p at their basolateral (blood) cell surface. H H OH Lumen Blood CO + – The m ost quantitatively im portant of these lum inal N a entry path- 2 Na H2CO3 K ways are shown here. These pathways are discussed in m ore detail HCO3 Cl CA in Figures 2-15 to 2-19. CA— carbonic anhydrase; Cl— chloride; H2O CO K 2 CO 2— carbon dioxide; H — hydrogen; H 2CO 3— carbonic acid; Na H CO 3— bicarbonate; K— potassium ; O H — hydroxyl ion. This com posite figure illustrates natriuretic and antinatriuretic m echanism s. For sim plicity, the system s are shown ↑ ERSNA ↑ Angiotensin II ↑ Aldosterone ↑ FF operating only in one direction and not all pathways are shown. The m ajor antinatriuretic system s are the renin-angiotensin-aldos- ↑ Activation of terone axis and increased efferent renal sym pathetic nerve activity ↑ Renin (ERSN A). The m ost im portant natriuretic m echanism is pressure baroreceptors natriuresis, because the level of renal perfusion pressure (RPP) determ ines the m agnitude of the response to all other natriuretic ↓ Arterial pressure system s. Renal interstitial hydrostatic pressure (RIH P) is a link between the circulation and renal tubular sodium reabsorption. Atrial natriuretic peptide (AN P) is the m ajor system ic natriuretic ECFV contraction horm one. W ithin the kidney, kinins and renom edullary prostaglandins are im portant m odulators of the natriuretic response of the kidney. AVP— arginine vasopressin; FF— filtration Normal ECF volume fraction. Angiotensinogen (or renin substrate) is a 56-kD glycoprotein produced and secreted by the liver. Renin is produced by the ACE juxtaglom erular apparatus of the kidney, as shown in Figures 2-8 and 2-9. Renin cleaves the 10 N -term inal am ino acids from SVR angiotensinogen. This decapeptide (angiotensin I) is cleaved by angiotensin converting enzym e (ACE). The resulting angiotensin II + + com prises the 8 N -term inal am ino acids of angiotensin I. The pri- Angiotensinogen m ary am ino acid structures of angiotensins I and II are shown in DRVYIHPFHL DRVYIHPF single letter codes. Angiotensin II increases system ic vascular resis- Angiotensin I Angiotensin II tance (SVR), stim ulates aldosterone secretion from the adrenal gland (indicated in gray), and increases sodium (N a) absorption by + + renal tubules, as shown in Figures 2-15 and 2-17. These effects Aldo decrease urinary N a (and chloride excretion; UN aV). This apparatus brings into close apposition the afferent B (A) and efferent (E) arterioles with the macula densa (M D), a specialized region of the thick ascending limb (TAL). The extraglomerular mesangium (EM ), or lacis “Goormaghtigh appa- N ratus (cells),” forms at the interface of these components. M D cells express the Na-K-2Cl JG (sodium-potassium-chloride) cotransporter (NKCC2) at the apical membrane [10,11]. By N A way of the action of this transporter, M D cells sense the sodium chloride concentration of luminal fluid. By way of mechanisms that are unclear, this message is communicated to JG cells located in and near the arterioles (especially the afferent arteriole).

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