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Biomedical subjects

L Gilson

Publications and source records attributed to L Gilson.

At least 37 records · Page 2Linked to original sources
PubMed1994

Reforming the health sector in developing countries: the central role of policy analysis.

Policy analysis is an established discipline in the industrialized world, yet its application to developing countries has been limited. The health sector in particular appears to have been neglected. This is surprising because there is a well recognized crisis in health systems, and prescriptions abound of what health policy reforms countries should introduce. However, little attention has been paid to how countries should carry out reforms, much less who is likely to favour or resist such policies. This paper argues that much health policy wrongly focuses attention on the content of reform, and neglects the actors involved in policy reform (at the international, national sub-national levels), the processes contingent on developing and implementing change and the context within which policy is developed. Focus on policy content diverts attention from understanding the processes which explain why desired policy outcomes fail to emerge. The paper is organized in 4 sections. The first sets the scene, demonstrating how the shift from consensus to conflict in health policy established the need for a greater emphasis on policy analysis. The second section explores what is meant by policy analysis. The third investigates what other disciplines have written that help to develop a framework of analysis. And the final section suggests how policy analysis can be used not only to analyze the policy process, but also to plan.

Africa↗
PubMed1994

Carrot and stick: state mechanisms to influence private provider behavior.

The behavior of private sector health care providers will depend critically on the environment within which they operate. A bewildering array of possible regulatory and incentive setting structures exist. Most developing countries have the basic legislation for regulation, but there are frequently difficulties in enforcing such controls. While process aspects of quality of care regulation are often the responsibility of professional organizations, these organizations may have limited incentives to be active in ensuring high quality medical car.e There has been less experience with the use of incentives to encourage appropriate behavior amongst private providers: this appears a promising area for further work. Above all, adequate information is essential both for the enforcement of regulations and the application of incentive mechanisms.

Consumer Organizations↗
PubMed1993

Assessment of process quality in Tanzanian primary care.

Process quality is the commonly used operational definition of health care quality. Its key components are technical and inter-personal skills, but most assessments undertaken in developing countries focus only on technical skills. This study from Tanzania used explicit observation checklists to review the process of providing antenatal, curative and nursing care in primary health units, assessing both technical and inter-personal skills. The study findings emphasize the weaknesses in available care, particularly in the attitudes of health staff but also in aspects of technical care. Differences in performance between health units appear to be influenced by factors such as workloads, structure and staff allocations. Differences between cadres were also identified and may underlie some of the inter-unit differences. The policy actions required to address the problems must reflect the diversity of the underlying influences, seeking to raise both technical and inter-personal quality, as the two are mutually reinforcing.

Child↗
PubMed1990

Genetic analysis of an MDR-like export system: the secretion of colicin V.

The extracellular secretion of the antibacterial toxin colicin V is mediated via a signal sequence independent process which requires the products of two linked genes: cvaA and cvaB. The nucleotide sequence of cvaB reveals that its product is a member of a subfamily of proteins, involved in the export of diverse molecules, found in both eukaryotes and prokaryotes. This group of proteins, here referred to as the 'MDR-like' subfamily, is characterized by the presence of a hydrophobic region followed by a highly conserved ATP binding fold. By constructing fusions between the structural gene for colicin V, cvaC, and a gene for alkaline phosphatase, phoA, lacking its signal sequence, it was determined that 39 codons in the N-terminus of cvaC contained the structural information to allow CvaC-PhoA fusion proteins to be efficiently translocated across the plasma membrane of Escherichia coli in a CvaA/CvaB dependent fashion. This result is consistent with the location of point mutations in the cvaC gene which yielded export deficient colicin V. The presence of the export signal at the N-terminus of CvaC contrasts with the observed C-terminal location of the export signal for hemolysin, which also utilizes an MDR-like protein for its secretion. It was also found that the CvaA component of the colicin V export system shows amino acid sequence similarities with another component involved in hemolysin export, HlyD. The role of the second component in these systems and the possibility that other members of the MDR-like subfamily will also have corresponding second components are discussed. A third component used in both colicin V and hemolysin extracellular secretion is the E. coli host outer membrane protein, TolC.

Alkaline Phosphatase↗
PubMed1989

What is the future for equity within health policy?

In spite of differences in meaning, equity is generally accepted as an important social and economic policy goal. However, recent policy debates suggest that this consensus is under challenge. This paper explores the current debate between the 'New Right' and its opponents, and how different approaches affect health policy. It is strongly argued that if equity is not to remain a misunderstood concept, it is essential to clarify the arguments in its favour, as well as the steps required to protect its position within policy. The paper then goes on to justify the concern with equity, the broad goals equity seeks to achieve, and the practical translation of these goals into health policy. In the final section essentially practical issues are raised, by considering planning strategies and what research is necessary to support and develop pragmatic planning based on equity goals.

Global Health↗
PubMed1989

National community health worker programs: how can they be strengthened?

This article is based on a collaborative research study of policy and practice in national community health worker (CHW) programs in developing countries. The study involved a review of the relevant literature, case studies in Botswana, Colombia and Sri Lanka, and an international workshop where the future of such programs was discussed. The findings of this research are discussed under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulties of maintaining quality. It is clear that existing national community health worker programs have suffered from conceptual and implementation problems. However, given the interest and political will, governments can address these problems by adopting more flexible approaches within their CHW programs, by planning for them within the context of all health sector activities rather than as a separate activity, and by immediately addressing weaknesses in task allocation, training and supervision. CHWs represent an important health resource, whose potential in extending coverage and providing a reasonable level of care to otherwise underserved populations must be fully tapped.

Botswana↗
PubMed1988

Health surveys in developing countries: the objectives and design of an international programme.

There have been calls recently for a major international effort to collect epidemiological information in developing countries. One approach to a World Health Survey is considered, namely single-round retrospective interview surveys. Surveys can contribute to the improvement of national health information systems by providing person-based, rather than episode-based, measures related to health that apply to the entire population. A programme of health interview surveys could be used to ascertain patterns of morbidity and mortality, to measure access to and use of health services and to develop and disseminate methodologies for collecting and analysing health related data. Single-round surveys could not be used to evaluate the impact of investments on health and would be of limited use for improving our understanding of the determinants of ill health. Attention is drawn to a number of conceptual, technical and logistic issues to be considered in the design of a World Health Survey.

Attitude to Health↗
PubMed1987

Four plasmid genes are required for colicin V synthesis, export, and immunity.

The colicin V production and immunity genes were isolated from plasmid pColV-K30. A HindIII-to-SalI fragment of 9.4 kilobases was cloned into the compatible vectors pBR322 and pACYC184. Mutants defective in colicin production were generated by Tn5 insertions and by constructing deletions in vitro. Physical analysis of these mutations identified a 4.4-kilobase region of this DNA which contains all the plasmid genes (cva) needed for the production of colicin V. The colicin V immunity determinant (cvi) is in a 700-base-pair fragment located within one end of this region. Complementation tests identified three genes, called cvaA, cvaB, and cvaC, required for colicin production. Analysis of the proteins labeled in minicells harboring various Tn5 insertions allowed us to identify protein products for the cvaA and cvaC genes. Mutations in cvaA and cvaB eliminated colicin activity in culture supernatants, but not within the cells. Mutations in cvaC, however, eliminated all detectable activity. From these results we conclude that the cvaC gene codes for the structural gene for colicin V, while cvaA and cvaB are apparently needed for the normal export of the colicin.

Bacterial Proteins↗
PubMedDate not supplied

The equity impacts of community financing activities in three African countries.

Although the Bamako Initiative from its very beginning was caught up in wider debates about the potential equity impact of any form of user financing, to date there has been little empirical investigation of this impact. This three-country study, undertaken in Benin, Kenya and Zambia in 1994/95, was initiated to add to the body of relevant evidence. It sought to understand not only what had been the equity impacts of community financing activities in these countries but also how they had been brought about. As a result, it investigated equity primarily through consideration of the design of these financing activities and through the perceptions of different actors, within a limited number of purposively selected geographical areas in each country, about their strengths and weaknesses. Additional data on utilization were either collected during the course of the study (Kenya) or drawn from other available studies (Benin and Zambia). Key issues considered in the studies' assessment of equity were the extent to which both relative and absolute affordability gains were achieved, as well as as an influence over both the distributional and procedural justice of the financing activities, the pattern of decision-making. Across countries there was evidence of relative affordability gains in Benin and Kenya, but Kenyan gains were not sustained over time and no such gains were identified in Zambia. In addition, no country had given attention either to the issue of absolute affordability, through the implementation of effective exemption mechanisms to protect the poorest from the burden of payment, or to the establishment of community decision-making bodies that effectively represented the interests of all groups including the poorest. Overall, therefore, although the Benin Bamako Initiative programme might be judged as successful in terms of what appear to be its own equity objectives, the other two countries' schemes had clear equity problems even in these terms. The experience across countries also highlights the unresolved question of whether equity is concerned with the greatest good for the greatest number or with promoting the interests of the most disadvantaged.

Benin↗
PubMedDate not supplied

Community health workers in national programmes: the case of the family welfare educators of Botswana.

Community health worker programmes have become a prominent feature of many primary health care schemes in developing countries. This paper, which is based on a larger collaborative study undertaken in 3 countries, focuses on the experiences with such workers in Botswana, and concludes that many of the key issues that were highlighted in the Botswana study are similar to those in other countries. These can be summarized under four headings: unrealistic expectations, poor initial planning, problems of sustainability, and the difficulty of maintaining quality of care. The future success of these workers will depend on their being integrated more systematically into local services, with concomitant strengthening of management support and supervision.

Botswana↗
PubMedDate not supplied

Health sector reforms in sub-Saharan Africa: lessons of the last 10 years.

Over the past 10 years the poorest countries, especially in Africa, have struggled with worsening economic conditions and reduced public finance for health services. Some governments have responded in a piecemeal fashion, reacting to internal and external pressures. Others have embarked on major reforms of various aspects of their health systems. This paper reviews two specific types of strategy that have been initiated by governments: reform of financing strategies, and reform of public sector organization and procedures. Particular attention is paid to the experience of introducing user fees, community financing and decentralization since these have been some of the most popular strategies. The paper describes the nature, objectives and extent of reforms. It then presents an evaluation framework related to the criteria of efficiency and equity, and evaluates current reform experience using this framework. It concludes that assessment of the potential impact of reforms on efficiency and equity is undermined by the limited duration of many reforms and the limited nature of existing evaluations. It is clear, however, that a policy package is required rather than implementation of isolated reform strategies, and that in order to design an effective policy package, more needs to be known about the implementation and operation of reforms--particularly with respect to the influence of context, actors and processes.

Africa South of the Sahara↗
PubMedDate not supplied

Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania.

BACKGROUND: A community-randomised trial was undertaken to assess the impact, cost, and cost-effectiveness of averting HIV-1 infection through improved management of sexually transmitted diseases (STDs) by primary-health-care workers in Mwanza Region, Tanzania. METHODS: The impact of improved treatment services for STDs on HIV-1 incidence was assessed by comparison of six intervention communities with six matched communities. We followed up a random cohort of 12,537 adults aged 15-54 years for 2 years to record incidence of HIV-1 infection. The total and incremental costs of the intervention were estimated (ingredients approach) and used to calculate the total cost per case treated, the incremental cost per HIV-1 infection averted, and the incremental cost per disability-adjusted life-year (DALY) saved. FINDINGS: During 2 years of follow-up, 11,632 cases of STDs were treated in the intervention health units. The baseline prevalence of HIV-1 infection was 4%. The incidence of HIV-1 infection during the 2 years was 1.16% in the intervention communities and 1.86% in the comparison communities. An estimated 252 HIV-1 infections were averted each year. The total annual cost of the intervention was US$59,060 (1993 prices), equivalent to $0.39 per head of population served. The cost for STD case treated was $10.15, of which the drug cost was $2.11. The incremental annual cost of the intervention was $54,839, equivalent to $217.62 per HIV-1 infection averted and $10.33 per DALY saved (based on Tanzanian life expectancy) or $9.45 per DALY saved (based on the assumptions of the World Development Report). In a sensitivity analysis of factors influencing cost-effectiveness, cost per DALY saved ranged from $2.51 to $47.86. INTERPRETATION: Improved management of STDs in rural health units reduced the incidence of HIV-1 infection in the general population by about 40%. The estimated cost-effectiveness of this intervention ($10 per DALY) compares favourably with that of, for example, childhood immunisation programmes ($12-17 per DALY). Cost-effectiveness should be further improved when the intervention is applied on a larger scale. Resources should be made available for this highly cost-effective HIV control strategy.

Adolescent↗