How and why public sector doctors engage in private practice in Portuguese-speaking African countries.
OBJECTIVE: To explore the type of private practice supplementary income-generating activities of public sector doctors in the Portuguese-speaking African countries, and also to discover the motivations and the reasons why doctors have not made a complete move out of public service. DESIGN: Cross-sectional qualitative survey. SUBJECTS: In 1996, 28 Angolan doctors, 26 from Guinea-Bissau, 11 from Mozambique and three from S Tome and Principe answered a self-administered questionnaire. RESULTS: All doctors, except one unemployed, were government employees. Forty-three of the 68 doctors that answered the questionnaire reported an income-generating activity other than the one reported as principal. Of all the activities mentioned, the ones of major economic importance were: public sector medical care, private medical care, commercial activities, agricultural activities and university teaching. The two outstanding reasons why they engage in their various side-activities are 'to meet the cost of living' and 'to support the extended family'. Public sector salaries are supplemented by private practice. Interviewees estimated the time a family could survive on their public sector salary at seven days (median value). The public sector salary still provides most of the interviewees income (median 55%) for the rural doctors, but has become marginal for those in the urban areas (median 10%). For the latter, private practice has become of paramount importance (median 65%). For 26 respondents, the median equivalent of one month's public sector salary could be generated by seven hours of private practice. Nevertheless, being a civil servant was important in terms of job security, and credibility as a doctor. The social contacts and public service gave access to power centres and resources, through which other coping strategies could be developed. The expectations regarding the professional future and regarding the health systems future were related mostly to health personnel issues. CONCLUSION: The variable response rate per question reflects some resistance to discuss some of the issues, particularly those related to income. Nevertheless, these studies may provide an indication of what is happening in professional medical circles in response to the inability of the public sector to sustain a credible system of health care delivery. There can be no doubt that for these doctors the notion of a doctor as a full-time civil-servant is a thing of the past. Switching between public and private is now a fact of life. (+info)
Maternal mortality in Guinea-Bissau: the use of verbal autopsy in a multi-ethnic population.
BACKGROUND: In developing countries with scanty resources it is very important to have reliable data to establish priorities for the health sector; e.g. to reduce maternal mortality it is necessary to determine the most important causes. The majority of deaths, however, occur without previous contact with the health system and consequently conventional analyses of death certificates are not feasible. Instead, studies have been carried out in some developing countries with various forms of post-mortem interviews, the so-called verbal autopsies (VA). METHODS: We developed a structured interview with filter questions, which was applied to all deaths of women of fertile age in a cohort of 10,000 women living in 100 clusters in Guinea-Bissau and followed over a period of 6 years. The cause of death was ascertained by means of a series of diagnostic algorithms for the most common causes of maternal mortality, including postpartum haemorrhage, antepartum haemorrhage, puerperal infection, obstructed labour, eclampsia, abortion, and ectopic pregnancy. RESULTS: Of the 350 deaths of women of fertile age, 32% were maternal and it seems unlikely that a significant proportion of maternal deaths have not been classified correctly. Using the diagnostic algorithm 70% could be given a specific diagnosis, the most important causes being postpartum haemorrhage (42% [29/69]), obstructed labour (19% [13/69]), and puerperal infection (16% [11/69]). We attempted to identify the factors that are critical for obtaining sufficient information to reach a diagnosis. In the univariate analyses, it was important whether the respondent had been present during the last illness (P = 0.04) and whether the death occurred more than one week after delivery (P = 0.04). The husband was a better respondent than a co-wife (P = 0.08), and men in general provided more specific information than women (P = 0.08). Furthermore, information appeared to be better if the woman had died in the rainy season (P = 0.08). The length of the recall period, parity, age of woman, place of death, rural/urban residence, and ethnic group were not decisive. In the multivariate analysis sex and presence of respondent and time after delivery were significantly associated with the risk of not reaching a specific diagnosis. Women are less likely to provide adequate information for a diagnosis than men (odds ratio [OR] 3.1; 95% confidence interval [CI]: 1.2-8.1). Respondents that did not reside in the village during the departed woman's illness/delivery carried equal risk of not reaching a conclusion (OR 3.1; CI: 1.1-9.1). Deaths occurring more than one week after delivery were also less likely to be classified (OR 6.1; CI: 1.7-22.0). CONCLUSION: The VA described in the present paper left 30% of the maternal deaths unclassified without a specific diagnosis. Had all interviews been with husbands, only 14% would have remained unclassified. If we had only asked people who were present during the terminal phase of the victim's illness the proportion of classified deaths would have risen from 70% to 75%. It is likely that delayed maternal deaths have not been adequately covered by the present algorithms, but they may also simply be more difficult to describe due to the duration of the disease episode. In contrast to methods by which cause of death is established by a panel of medical experts, the present VA should be economically and technically viable in areas where health workers have only minimal training. (+info)
Early two-dose measles vaccination schedule in Guinea-Bissau: good protection and coverage in infancy.
BACKGROUND: Previous studies from Africa have suggested that there is little benefit to be gained from early two-dose measles vaccination schedules. Two-dose schedules have been associated with no improvement in coverage due to immunization of the same individuals on both occasions, low return rate, high refusal rate, low vaccine efficacy, and fear of blunting of the antibody response. Because of the poor results achieved previously with two-dose measles vaccination schedules, we studied patterns of participation, reasons for non-participation, vaccination coverage and relative efficacy of a one-dose versus a two-dose schedule in connection with the implementation of an early two-dose trial in Guinea-Bissau. METHODS: Children born from September 1994 to January 1996 were randomized into two groups receiving either two doses of measles vaccine at 6 and 9 months or one dose of inactivated polio vaccine (IPV) at 6 months and measles vaccine at 9 months. RESULTS: At 6 months of age 86% (1869/2181) of the children participated, and at 9 months of age participation was 87% (1775/2035). The return rate for obtaining a second dose of vaccine was 93% (1647/1773). The main reason for not participating was travelling (78%). Around 50% of those who did not take part in one vaccination took part in the other. When only children participating the first time they were called for a measles vaccination were included, the measles vaccination coverage in the one-dose group was 59% versus 80% in the two-dose group, i.e. a 50% reduction in the risk of not being vaccinated (relative risk [RR] 0.50; confidence interval [CI]: 0.43-0.57). Few measles cases have occurred in the study area since the implementation of the trial making precise estimation of the relative efficacy of the two vaccine strategies difficult, but all seven clinically diagnosed measles cases occurred in the one-dose group making the relative efficacy for the two-dose group compared with the one-dose group 100% (95% CI: 35%-100%; two-tailed P = 0.016). When including maternal reports, the relative efficacy was 90% (95% exact confidence interval; two-tailed P = 25%-97%, P = 0.022). CONCLUSION: In this study of a two-dose measles immunization schedule at 6 and 9 months of age there was no sign of low participation or poor return rates. The risk of not being vaccinated was lower in the two-dose group than in the one-dose group, and the relative efficacy of a two-dose versus a one-dose schedule was high. Although our results were obtained within a trial where dedicated personnel informed every participant personally about the study, we believe our results indicate that with thorough information about the population it may be possible to achieve a higher coverage with a two-dose measles vaccination schedule than a one-dose schedule. A two-dose schedule may be a feasible way to resolve the problems of low coverage and severe measles infection among infants. (+info)
First do no harm: making oral rehydration solution safer in a cholera epidemic.
Oral rehydration solution (ORS) is lifesaving therapy for cholera and pediatric diarrhea. During a cholera epidemic in Guinea-Bissau, we evaluated the microbiologic quality of ORS prepared at a hospital and tested a simple intervention using special vessels for disinfecting tap water with bleach and for preparing, storing, and dispensing ORS. Few coliform bacteria and Escherichia coli were recovered from tap water; however, pre-intervention ORS contained numerous bacteria including E. coli and toxigenic Vibrio cholerae O1. In contrast, ORS samples from intervention vessels had few or no coliform bacteria, no E. coli, and no V. cholerae. Mean pre-intervention counts of coliform bacteria (3.4 x 10(7) colony-forming units [cfu]/100 ml) and E. coli (6.2 x 10(3) cfu) decreased significantly during the intervention period to 3.6 x 10(2) cfu and 0 cfu, respectively (P < 0.001). This simple system using bleach disinfectant and special storage vessels prevents bacterial contamination of ORS and reduces the risk of nosocomial transmission of cholera and other enteric pathogens. (+info)
Malaria parasitemia and childhood diarrhea in a peri-urban area of Guinea-Bissau.
To examine the association between diarrhea in early childhood and malaria parasitemia, we conducted a nested case-control study in Guinea-Bissau of 297 children with diarrhea and a similar number of children without diarrhea matched for age, season, and residential area. There were no associations between diarrhea and parasite rate, parasite density, or clinical malaria. However, anti-malarials were easily available and frequently used, which was reflected by a 0.7% prevalence of children with a parasite density > 100/200 leukocytes. Thus, the findings do not preclude that diarrhea may be a sign of clinical malaria or high-parasite density in endemic areas with lower use of antimalarials. (+info)
Molecular characterization of human immunodeficiency virus (HIV)-1 and -2 in individuals from guinea-bissau with single or dual infections: predominance of a distinct HIV-1 subtype A/G recombinant in West Africa.
Guinea-Bissau in West Africa has the highest prevalence of human immunodeficiency virus (HIV)-2 infection in the world, but recently the HIV-1 prevalence increased rapidly with the subsequent appearance of HIV-1 and HIV-2 dual infections. Information about the genetic subtypes of HIV in the region is limited. Therefore, we characterized the env V3 region of HIV-1 and HIV-2 variants through direct DNA sequencing of peripheral blood mononuclear cell samples from 18 individuals with HIV-1 only and 9 individuals with dual infection. Phylogenetic analyses of these new sequences and database sequences from other West African countries showed that all HIV-1 and HIV-2 sequences from singly as well as dually infected individuals, except one, clustered among HIV-1 subtype A and HIV-2 subtype A, respectively. Importantly, a majority of the HIV-1 sequences from Guinea-Bissau and neighbouring countries were closely related with the isolates IbNG, DJ263, and DJ264, which share a common subtype A/G recombination pattern. Analysis of pol gene sequences from selected HIV-1 variants showed that "IbNG-like" viruses in Guinea-Bissau are also recombinant, indicating that the HIV-1 epidemic in Guinea-Bissau and neighbouring countries is dominated by an epidemic spread of a distinct subtype A/G recombinant, which is strikingly similar to the epidemic spread of a subtype A/E recombinant in Southeast Asia. Furthermore, the HIV-1 and HIV-2 variants carried by individuals with dual infection were intermixed with variants from singly infected individuals, indicating that variants involved in dual and single infections have common epidemiological histories. (+info)
Nutritional status and mortality of refugee and resident children in a non-camp setting during conflict: follow up study in Guinea-Bissau.
OBJECTIVE: To study the effects on children of humanitarian aid agencies restricting help to refugee families (internally displaced people). DESIGN: Follow up study of 3 months. SETTING: Prabis peninsular outside Bissau, the capital of Guinea-Bissau, which has functioned as a refugee area for internally displaced people in the ongoing war, and the study area of the Bandim health project in Bissau. PARTICIPANTS: 422 children aged 9-23 months in 30 clusters. MAIN OUTCOME MEASURES: Mid-upper arm circumference and survival in relation to residence status. RESULTS: During the refugee situation all children deteriorated nutritionally, and mortality was high (3.0% in a 6 week period). Rice consumption was higher in families resident in Prabis than in refugees from Bissau but there was no difference in food expenditure. Nutritional status, measured by mid- upper arm circumference, was not associated with rice consumption levels in the family, and the decline in circumference was significantly worse for resident than for refugee children; the mid-upper arm circumference of refugee children increased faster than that of resident children. For resident children, mortality was 4.5 times higher (95% confidence interval 1.1 to 30.0) than for refugee children. Mortality for both resident and refugee children was 7.2 times higher (1.3 to 133.9) during the refugee's stay in Prabis compared with the period after the departure of the refugees. CONCLUSION: In a non-camp setting, residents may be more malnourished and have higher mortality than refugees. Major improvements in nutritional status and a reduction in mortality occurred in resident and refugee children as soon as refugees returned home despite the fact that there was no improvement in food availability. (+info)
Evolution and clonal traits of Mycobacterium tuberculosis complex in Guinea-Bissau.
Two hundred twenty-nine consecutive isolates of Mycobacterium tuberculosis complex from patients with pulmonary tuberculosis in Guinea-Bissau, which is located in West Africa, were analyzed for clonal origin by biochemical typing and DNA fingerprinting. By using four biochemical tests (resistance to thiophene-2-carboxylic acid hydrazide, niacin production, nitrate reductase test, and pyrazinamidase test), the isolates could be assigned to five different biovars. The characteristics of four strains conformed fully with the biochemical criteria for M. bovis, while those of 85 isolates agreed with the biochemical criteria for M. tuberculosis. The remaining 140 isolates could be allocated into one of three biovars (biovars 2 to 4) representing a spectrum between the classical bovine (biovar 1) and human (biovar 5) tubercle bacilli. By using two genotyping methods, restriction fragment length polymorphism analysis with IS6110 (IS6110 RFLP analysis) and spoligotyping, the isolates could be separated into three groups (groups A to C) of the M. tuberculosis complex. Group A (n = 95), which contained the majority of classical human M. tuberculosis isolates, had large numbers of copies of IS6110 elements (mean number of copies, 9) and a distinctive spoligotyping pattern that lacked spacers 33 to 36. Isolates of the major group, group B (n = 119), had fewer IS6110 copies (mean copy number, 5) and a spoligotyping pattern that lacked spacers 7 to 9 and 39 and mainly comprised isolates of biovars 1 to 4. Group C isolates (n = 15) had one to three IS6110 copies, had a spoligotyping pattern that lacked spacers 29 to 34, and represented biovar 3 to 5 isolates. Four isolates whose biochemical characteristics conformed with those of M. bovis clustered with the group B isolates and had spoligotype patterns that differed from those previously reported for M. bovis, in that they possessed spacers 40 to 43. Interestingly, isolates of group B and, to a certain extent, also isolates of group C showed a high degree of variability in biochemical traits, despite genotypic identity in terms of IS6110 RFLP and spoligotype patterns. We hypothesize that isolates of groups B and C have their evolutionary origin in West Africa, while group A isolates are of European descent. (+info)