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PubMed2006

The future of Chagas disease control.

In the past 15 years, there have been major advances in the control of Chagas disease in most of the countries endemic for this infection. Attention now turns to the future continuity of surveillance and control interventions - especially in regions where control has been so successful that the epidemiological significance of Chagas disease is in steep decline. The effort and expenditure of the recent past cannot continue indefinitely, but a degree of surveillance and selective intervention will be required because of the risk of new infestations and infections resulting from adventitious silvatic vectors accidentally entering houses. In this review, we summarize the progress of multinational control initiatives against Chagas disease. In addition, we suggest that the most sustainable approach to future surveillance involves both the primary healthcare system and university-based teams, with progressively greater attention given to case detection and treatment. Such an idea is not new, but we believe that it merits extensive discussion because of the different ways that research and health interventions are financed and because of the need to establish clearer reporting links between the research communities and the national health authorities.

Adolescent↗
PubMedDate not supplied

Threats to family planning services in Michigan: organizational responses to economic and political challenges.

Title X is the only federal funding specifically for contraception and family planning services. This study identifies the threats and challenges Title X family planning organizations face in Michigan, and examines organizational responses to these challenges. We hypothesized that organizational responses to current challenges, including recent legislation, would differ between organizational types. We used a multiple case study design to examine safety net providers that received Title X funding in 2001. Cases were selected to represent economic and geographic diversity and included a mix of population densities. Key informants at each organization participated in face-to-face, semistructured interviews. Interviews collected data on current challenges, organizational planning processes, and organizational responses. All Title X organizations reported significant challenges, including rising costs, increasing need, and inadequate funding. Private organizations were more concerned about political challenges, especially recent Michigan legislation, than health departments. Organizational type was associated with the type of response. Health departments tended to close clinics or cut services, whereas private organizations recruited insured populations and increased patient fees. Based on these findings, the family planning safety net in Michigan appears to be undergoing significant change. These changes may decrease the availability of affordable family planning services in Michigan.

Community Health Centers↗
PubMed1995

Integration of primary health care concepts in a children's hospital with limited resources.

After nearly 30 years of war, health services in Vietnam were devastated. Pediatric Hospital Number 1 (PH1) in Ho Chi Minh City was severely overloaded, mortality rates for readily treatable diseases were high, and staff competence and motivation were low. In 1988, PH1 introduced primary health care (PHC) concepts into the policy of the hospital. The approach included identification of priority diseases that are most easily treatable (diarrhoea, acute respiratory infections, Dengue haemorrhagic fever, malnutrition, and common paediatric emergencies including malaria); establishment of training programmes through paediatric priority training units for medical staff of PH1 and health centres (district and commune services), and health education for the patients' carers; promotion of outpatient treatment to avoid unnecessary admissions; use of appropriate technology such as essential drugs and application of WHO guidelines; support for health centres; transfer of responsibility for decision-making from one central authority to each department; and community participation, by which we sought small contributions from families who could afford to pay. Since the new approach was implemented, the numbers of admissions have fallen substantially. Mortality rates have decreased greatly (diarrhoea by 80%, Dengue fever by 64%, and acute respiratory infections by 41%). Support from foreign non-governmental organisations has enabled training and research to enhance staff skill and knowledge and supply of necessary equipment.(ABSTRACT TRUNCATED AT 250 WORDS)

Community Health Services↗
PubMed2003

International NGOs and primary health care in Mozambique: the need for a new model of collaboration.

In keeping with the neo-liberal emphasis on privatization, international aid has been increasingly channeled through non-governmental organizations (NGOs) and their expatriate technical experts to support primary health care (PHC) in the developing world. Relationships between international aid workers and their local counterparts have thus become critical aspects of PHC and its effectiveness. However, these important social dynamics of PHC remain understudied by social scientists. Based on three years of participant-observation in Mozambique, this paper presents an ethnographic case study of these relationships in one central province. The Mozambique experience reveals that the deluge of NGOs and their expatriate workers over the last decade has fragmented the local health system, undermined local control of health programs, and contributed to growing local social inequality. Since national health system salaries plummeted over the same period as a result of structural adjustment, health workers became vulnerable to financial favors offered by NGOs seeking to promote their projects in turf struggles with other agencies. It is argued that new aid management strategies, while necessary, will not be sufficient to remedy the fragmentation of the health sector. A new model for collaboration between expatriate aid workers and their local counterparts in the developing world is urgently needed that centers on the building of long-term equitable professional relationships in a sustainable adequately funded public sector. The case study presented here illustrates how the NGO model undermines the establishment of these relationships that are so vital to successful development assistance.

Community Health Services↗
PubMed1996

Considerations for regional health authorities in the provision of environmental health services.

As population health programs, environmental health services differ fundamentally from other forms of health service delivery. At a time when the health sector is striving for integration, the incorporation of these unique services into the delivery system presents a unique challenge to policy makers and administrators across the country. The University of Alberta recently completed a comprehensive review and redesign of locally governed and delivered environmental health protection services in Alberta. This paper outlines the key issues and unique features surrounding the delivery of environmental health services and presents the study team's suggested approach to addressing these issues.

Alberta↗
PubMed1995

Implementing the Health Care Quality Improvement Program in the Medicare ESRD Program: a new era of quality improvement in ESRD.

Improving the quality of health care is a central challenge for America's health care system. The mission of the End-Stage Renal Disease (ESRD) program is to promote the quality, effectiveness, and efficiency of ESRD patient care and program administration. The program provides an ideal opportunity to demonstrate the use of information to help clinicians analyze and improve the care they deliver to patients in an ambulatory setting. This is possible because the program has established regional surveillance systems, called ESRD Networks, that gather information on the occurrence and outcomes of treatment of Medicare beneficiaries with ESRD. The Health Care Financing Administration, which is responsible for the administration of the program, and the renal community have worked together since 1990 to identify ways of incorporating new methods of quality improvement into the program. These methods include statistical evaluation of the processes and outcomes of care in dialysis populations; communicating recommended practices with clinical guidelines and algorithms; regional peer review and feedback (ie, technical assistance and/or collaborations for quality improvement); interventions that focus on the provision of assistance for quality improvement efforts; continuing collection and active feedback of data to providers; and a commitment to continue to evaluate and revise quality improvement activities to reflect lessons learned and newly identified needs. These ideas have been included in the 1994-1997 scope of work for the ESRD Networks and is called the ESRD Health Care Quality Improvement Program (HCQIP). This article describes the background for the ESRD HCQIP and the program's elements.

Humans↗
PubMed2000

Health technology assessment in Belgium.

The Belgian healthcare system has a Bismarck-type compulsory health insurance, covering almost the entire population, combined with private provision of care. Providers are public health services, independent pharmacists, independent ambulatory care professionals, and hospitals and geriatric care facilities. Healthcare responsibilities are shared between the national Ministries of Public Health and Social Affairs, and the Dutch-, French-, and German-speaking Community Ministries of Health. The national ministries are responsible for sickness and disability insurance, financing, determination of accreditation criteria for hospitals and heavy medical care units, and construction of new hospitals. The six sickness and disability insurance funds are responsible for reimbursing health service benefits and paying disability benefits. The system's strength is that care is highly accessible and responsive to patients. However, the healthcare system's size remained relatively uncontrolled until recently, there is an excess supply of certain types of care, and there is a large number of small hospitals. The national government created a legal framework to modernize the insurance system to control budgetary deficits. Measures for reducing healthcare expenditures include regulating healthcare supply, healthcare evaluation, medical practice organization, and hospital budgets. The need to control healthcare facilities and quality of care in hospitals led to formal procedures for opening hospitals, acquiring expensive medical equipment, and developing highly specialized services. Reforms in payment and regulation are being considered. Health technology assessment (HTA) has played little part in the reforms so far. Belgium has no formal national program for HTA. The future of HTA in Belgium depends on a changing perception by providers and policy makers that health care needs a stronger scientific base.

Belgium↗
PubMed2001

Managing the entry of new medicines in the National Health Service: health authority experiences and prospects for primary care groups and trusts.

For the most part, the management of new medicines in the NHS has hitherto been a matter for local discretion. The result is that access to medicines is often determined by where a patient lives, as opposed to some nationally agreed clinical criteria. This "postcode prescribing" has led to widespread variations in access to medicines and concerns about the resulting inequalities. Primary care groups and trusts are expected to reduce variations in access to care, whilst at the same time balancing their finances, since any overspends on prescribing must be covered by disinvestment in hospital and community services. We interviewed 21 health authority (HA) prescribing advisers to ascertain how they viewed the managed entry of new medicines in order to identify lessons for PCGs. In addition, we report the views of local prescribing managers on the potential impact of recent government policy changes on the process and speculate on the likely implications of these for primary care groups and trusts. What is clear from the study is that HAs often have no explicit objective in relation to new medicines, but that their desire to act is prompted by fears of overspending on prescribing budgets. The danger of this approach is that patients may be denied cost-effective treatments since all new medicines are seen as a problem. It seems likely that PCG/Ts will face the same dilemmas with which the HA advisers in our study have been wrestling for some time. Recent policy changes in relation to prescribing budgets and new medicines are likely to exacerbate these problems. The tensions between local priority setting, which may mean saying no to new medicines, whilst at the same time eradicating postcode prescribing and balancing budgets means that PCG/Ts face difficult policy choices.

Budgets↗
PubMedDate not supplied

Translation squared: improving asthma care for high-disparity populations through a safety net practice-based research network.

To assess the effectiveness of an intervention designed to increase compliance with national asthma care guidelines in primary care safety net health centers serving high-disparity patient populations, we conducted a group-randomized controlled trial (seven intervention sites and nine control sites) in federally funded community health centers in eight southeastern states. There were three components involved in the intervention: resources (asthma kits including peak flow meter, MDI spacer device, plus educational materials), training of all health center staff in asthma care guidelines, and tools or templates for practice-level systems change (asthma flow sheets and standing orders). Control group sites received only copies of the national asthma guidelines. Chart reviews were performed to determine practitioner's compliance with national guidelines for asthma care. Clinicians practicing in intervention health centers showed significantly (p < 0.01) greater improvement on some measures than did the control health centers, although postintervention compliance with guidelines was still suboptimal. Disseminating national guidelines is not enough. Providing training and guideline-specific resources, in combination with tools for practice change, improved care significantly even in safety net health centers serving high-disparity patient populations.

Asthma↗
PubMed1998

Mixed feelings: satisfaction and disillusionment among Australian GPs.

BACKGROUND AND AIMS: Medical practitioners' satisfaction with their work impacts on quality of care for their patients and on their own sense of fulfillment. Reforms introduced in the early 1990s into Australian general practice have led to concerns over the morale of GPs. This study examines satisfaction and dissatisfaction of GPs with regard to the reform strategy. METHOD: GPs throughout Australia were approached via a popular GP magazine to express their views in a questionnaire comprising closed-end and open-ended questions enquiring about satisfaction with their current role and sources of satisfaction (and dissatisfaction) of working in general practice. Factor analysis was used to identify different sources of satisfaction (and dissatisfaction), which were intercorrelated and which together represented underlying factors. Logistic regression modelling was used to determine which sources were most strongly associated with being satisfied (or not satisfied), and to explore GP characteristics associated with satisfaction. RESULTS: A total of 2186 questionnaires were returned, representing the opinions of 14-18% of Australian GPs. Two-thirds (68%) of respondents reported being satisfied, most frequently with the variety of work and establishing relationships with patients and their families. Six satisfaction factors were identified on factor analysis, the most important characterizing social and interpersonal roles. Leading sources of dissatisfaction related to perceived interference by the government. Six dissatisfaction factors were identified on factor analysis, the most important characterizing governmental issues. However, on logistic regression other sources of dissatisfaction (reflecting disillusionment) were most strongly associated with not being satisfied. CONCLUSIONS: The main sources of satisfaction are those which typify the long-term caring role of the community GP. While the reform strategy aimed to address problems with the organization and financing of general practice, the resulting intervention is the focus of dissatisfaction. Among dissatisfied GPs these attitudes may arise primarily from a sense of disillusionment.

Adult↗
PubMed2002

A comparative cost analysis of insecticide-treated nets and indoor residual spraying in highland Kenya.

The relative cost of indoor residual house-spraying (IRS) versus insecticide-treated bednets (ITNs) forms part of decisions regarding selective malaria prevention. This paper presents a cost comparison of these two approaches as recently implemented by Merlin, a UK emergency relief organization funded through international donor support and working in the highland districts of Gucha and Kisii in Kenya. The financial costs (cash expenditures) and the economic costs (including the opportunity costs of using existing staff and volunteers, and an annualized cost for capital items) were assessed. The financial cost for IRS was US dollars 0.86 per person protected, compared with 4.21 dollars for ITNs (reducing to 3.42 dollars to the provider assuming cost recovery). The economic cost per person protected for IRS was 0.88 dollars, compared with 2.34 dollars for ITNs. The costs for ITNs were sensitive to the number of nets sold per community group ('efficiency'), as the delivery costs constituted upwards of 40% of the total cost. However, even marked increases in efficiency of these groups could not reduce the costs of ITNs to that comparable with IRS, except if more than one cycle of IRS was needed. The implications of predicted reductions in the cost of insecticide for both IRS and ITNs are also explored. The provision of itemized cost data allows predictions to be made on changes in the design of these programmes. Under almost all design scenarios, IRS would appear to be a more cost-efficient means of vector control in the Kenyan highlands.

Bedding and Linens↗
PubMed1994

Supports for community-based mental health care: an optimistic review of federal legislation.

For the past 50 years, federal legislation has been a key force in shaping the delivery of public mental health services. This article describes and summarizes recent relevant federal legislative initiatives and analyzes their potential in providing support, either explicit or implicit, for community-based mental health care for adults in the United States. These legislative mandates and options can be a source of optimism and ammunition for advocates and change agents as they continue to work vigorously to improve the mental health services system.

Community Mental Health Services↗