Controlling schistosomiasis: the cost-effectiveness of alternative delivery strategies.
(9/1477)
Sustainable schistosomiasis control cannot be based on large-scale vertical treatment strategies in most endemic countries, yet little is known about the costs and effectiveness of more affordable options. This paper presents calculations of the cost-effectiveness of two forms of chemotherapy targeted at school-children and compares them with chemotherapy integrated into the routine activities of the primary health care system. The focus is on Schistosoma haematobium. Economic and epidemiological data are taken from the Kilombero District of Tanzania. The paper also develops a framework for possible use by programme managers to evaluate similar options in different epidemiological settings. The results suggest that all three options are more affordable and sustainable than the vertical strategies for which cost data are available in the literature. Passive testing and treatment through primary health facilities proved the most effective and cost-effective option given the screening and compliance rates observed in the Kilombero District. (+info)
The role of private providers in maternal and child health and family planning services in developing countries.
(10/1477)
This paper uses data from the Demographic and Health Surveys program (DHS) in 11 countries in Asia, Africa, and Latin America to explore the contribution of private health care providers to population coverage with a variety of maternal and child health and family planning services. The choice of countries and services assessed was mainly determined by the availability of data in the different surveys. Private providers contribute significantly to family planning services and treatment of children's infectious diseases in a number of the countries studied. This is as expected from the predictions of economic theory, since these goods are less subject to market failures. For the more 'public goods' type services, such as immunization and ante-natal care, their role is much more circumscribed. Two groups of countries were identified: those with a higher private provision role across many different types of services and those where private provision was limited to only one or two types of the services studied. The analysis identified the lack of consistent or systematic definitions of private providers across countries as well as the absence of data on many key services in most of the DHS surveys. Given the significance of private provision of public health goods in many countries, the authors propose much more systematic efforts to measure these variables in the future. This could be included in future DHS surveys without too much difficulty. (+info)
Cooperation or conflict over child health surveillance? Views of key actors.
(11/1477)
OBJECTIVE: To describe the views of general practitioners, health visitors, and clinical medical officers on child health surveillance, recent changes, perceptions of each other's roles, and attitudes to audit. DESIGN: Postal questionnaire survey. SETTING: Three health districts in North West Thames health region. SUBJECTS: All 602 general practitioners, 272 health visitors, and 42 clinical medical officers in these districts. MAIN MEASURES: Attitudes to and perceptions of child health surveillance and audit. Questionnaires were completed by 440 general practitioners (response rate 73%), 164 health visitors (60%), and 39 clinical medical officers (93%). RESULTS: Attitudes to child health surveillance were less positive among general practitioners than health visitors or clinical medical officers. Few respondents agreed that child health surveillance was a cost effective use of general practitioners' time (general practitioners 28%, 113/407; health visitors 28%, 40/145; clinical medical officers 39%, 15/39) and most thought that health visitors should carry out more of the doctors' examinations (68%, 262/387; 65%, 89/136; 66%, 25/38). General practitioners thought that clinical medical officers were less supportive than other relevant groups of their doing more child health surveillance. Most (72%, 105/146) health visitors thought that the 1990 contract had reduced parental choice of where to attend for child health surveillance. General practitioners were less enthusiastic than health visitors about most forms of clinical audit. CONCLUSIONS: Despite reservations about the impact of recent changes all groups were willing to explore innovative ways of delivering child health surveillance. IMPLICATIONS: There is scope for health visitors to increase their responsibilities and for more varied relationships between general practitioners and community child health doctors. (+info)
Integrating MCH/FP and STD/HIV services: current debates and future directions.
(12/1477)
The issue of integrating MCH/FP and STD/HIV services has gained an increasingly high priority on public health agendas in recent years. In the prevailing climate of health sector reform, policy-makers are likely to be increasingly pressed to address the broader concept of "reproductive health' in the terms consolidated at the Cairo International Conference on Population and Development, and the UN Conference on Women in Beijing. Integrated MCH/FP and STD/HIV services could be regarded as a significant step towards providing integrated reproductive health services, but clarity of issues and concerns is essential. A number of rationales have emerged which argue for the integration of these services, and many concerns have been voiced. There is little consensus, however, on the definition of "integrated services' and there are few documented case studies which might clarify the issues. This paper reviews the context in which rationales for "integrated services' emerged, the issues of concern and the case studies available. It concludes by suggesting future directions for research, noting in particular the need for country-specific and multi-dimensional frameworks and the appropriateness of a policy analysis approach. (+info)
Cost-effective treatment for severely malnourished children: what is the best approach?
(13/1477)
In urban Bangladesh, 437 children with severe malnutrition aged 12-60 months were sequentially allocated to treat either as i) inpatients, ii) day care, or iii) domiciliary care after one week of day care. Average institutional cost (US$) to achieve 80% weight-for-height were respectively $156, $59 and $29/child. As a proportion of the overall costs, staff salaries were the largest component, followed by laboratory tests. Parental costs were highest for domiciliary care, as no food supplements were provided. Nevertheless it was the option most preferred by parents and when the institutional and parental costs were combined, domiciliary care was 1.6 times more cost-effective than day care, and 4.1 times more cost-effective than inpatient care. CONCLUSION: With careful training and an efficient referral system, domiciliary care preceded by one week of day care is the most cost-effective treatment option for severe malnutrition in this setting. (+info)
Economic advantages of breast-feeding in an HMO: setting a pilot study.
(14/1477)
We performed a pilot study on newborns randomly chosen from term singleton deliveries born to mothers in an HMO group between September 1992 and August 1993. Breast-fed infants were breast-feeding at 6 months (n = 41), whereas bottle-fed infants were bottle-fed from birth (n = 107), Medical care and costs for the first 12 months were retrospectively analyzed, including office visits, drug prescriptions, and hospitalizations. Both groups had similar numbers of office visits and pharmacy costs. Breast-fed infants had fewer inpatient admissions (0.13 vs. 0.20 discharges per 1,000 babies), and their average total medical costs were $200 less than those of bottle-fed infants. Extrapolating to the total number of deliveries during this period, an increase in breast-feeding from the current rate (17%) to the Healthy People 2000 goal (50%) could save up to $140,000 annually. (+info)
Enhancing health programme efficiency: a Cambodian case study.
(15/1477)
In 1995, the Cambodian Urban Health Care Association (CUHCA) was set up as facilitator between private health care providers and patients, guaranteeing good quality health care and fair pricing to patients and providing training and logistic support to providers. Providers were engaged on a fee-for-service basis and competition encouraged. CUHCA's objectives followed the same line of thought as the 1993 World Development Report, aiming at influencing the unregulated private health care market through competition mechanisms. But soon after the start of the project the basic problem was recognized to be not the absence of effective government regulation but rather that consumers lack the requisite knowledge to make good choices in the market for health services. CUHCA had not adequately addressed the demand for health services. The original supply-side strategy of improving health services by increasing competition was a failure. In order to improve CUHCA's health programme efficiency the association's objectives were subsequently redefined and its functioning reorganized. CUHCA now tries to educate consumers and provides good quality services so that consumers will be able to act on the basis of their newly acquired knowledge. CUHCA's health centres serve as model clinics for first-line health care. Community educators organize information, education and communication (IEC) activities. Staff help school teachers to improve formal health education in schools and CUHCA assists local leaders in sanitation development. Only full-time personnel are employed, encouraging team spirit and communication with the target population. Salaries are based on team performance. The CUHCA programme demonstrates that, depending on the market situation, health programme models need to address both the supply and the demand for services in order to be efficient. Where consumers lack essential knowledge to make appropriate choices in the health service market, interventions should focus on health education and social marketing and provide models of quality care catering to informed consumer choice. (+info)
The quality of private and public primary health care management of children with diarrhoea and acute respiratory infections in Tlaxcala, Mexico.
(16/1477)
In Tlaxcala, Mexico, 80% of the children who died from diarrhoea or acute respiratory infections (ARI) in 1992-1993 received medical care; in more than 70% of cases it was provided by a private general practitioner (GP). The present study evaluated the quality of case management by private and public GPs to children under five years of age with diarrhoea and ARI. During the clinical observation, the treatment and counselling given to the mother were assessed with the WHO guidelines as reference standard. A total of 41 private and 40 public GPs were evaluated for the management of diarrhoea, and 59 private and 40 public GPs for the management of ARI. For diarrhoea, half of the private GPs gave inadequate rehydration therapy, 63% gave incorrect advice on diet, 66% and 49% made an incorrect correct decision in the prescription of antimicrobial and symptomatic drugs, respectively. Public GPs generally performed better in diarrhoea management: 7% gave inadequate rehydration therapy, 13% gave wrong advice on diet, 3% made a wrong decision in the prescription of symptomatic drugs and 28% gave a wrong decision in antimicrobial prescription. In the management of ARI, 66% and 58% of private GPs made a wrong decision in the prescription of antimicrobial and symptomatic drugs, respectively, compared to 30% and 20% of public GPs, respectively. Counselling to the mother given by both private and public GPs was considered inadequate in most cases of diarrhoea and ARI. These results clearly show that private doctors, as important providers of medical care, need to be included in the strategies to improve the quality of care of children with diarrhoea and ARI. Future research needs to address the determinants of the clinical practice of private doctors in countries like Mexico. (+info)