The existence of tropical sprue in Africa is controversial. In this paper we present 31 cases seen in Rhodesia over a 15 month period. They have the clinical features, small intestinal morphology, malabsorption pattern, and treatment response of tropical sprue. Other causes of malabsorption, and primary malnutrition, have been excluded. The severity of the clinical state and intestinal malabsorption distinguish these patients from those we have described with tropical enteropathy. The previous work on tropical sprue in Africa is reviewed and it is apparent that, when it has been adequately looked for, it has been found. It is clear that the question of tropical sprue in Africa must be re-examined and that it existence may have hitherto been concealed by the assumption that primary malnutrition is responsible for the high prevalence of deficiency states. (+info)
Tropical enteropathy in Rhodesia.
Tropical enteropathy, which may be related to tropical sprue, has been described in many developing countries including parts of Africa. The jejunal changes of enteropathy are seen in Rhodesians of all social and racial categories. Xylose excretion, however, is related to socioeconomic status, but not race. Upper socioeconomic Africans and Europeans excrete significantly more xylose than lower socioeconomic Africans. Vitamin B12 and fat absorption are normal, suggesting predominant involvement of the proximal small intestine. Tropical enteropathy in Rhodesia is similar to that seen in Nigeria but is associated with less malabsorption than is found in the Caribbean, the Indian subcontinent, and South East Asia. The possible aetiological factors are discussed. It is postulated that the lighter exposure of upper class Africans and Europeans to repeated gastrointestinal infections may accound for their superior xylose absorption compared with Africans of low socioeconomic circumstances. It is further suggested that the milder enteropathy seen in Africa may be explained by a lower prevalence of acute gastroenteritis than in experienced elsewhere in the tropics. (+info)
Paralytic poliomyelitis associated with live oral poliomyelitis vaccine in child with HIV infection in Zimbabwe: case report.
OBJECTIVE: To describe a complication of oral vaccination with live, attenuated poliomyelitis virus in a child infected with HIV. DESIGN: Case report. SETTING: Teaching hospital in Harare, Zimbabwe. SUBJECTS: A boy of 41/2 years and his mother. MAIN OUTCOME MEASURES: Results of clinical and laboratory investigations. RESULTS: Two weeks after receiving the second dose of oral poliomyelitis vaccine during national immunisation days the child developed paralysis of the right leg. He had a high titre of antibodies against poliovirus type 2, as well as antibodies against HIV-1, a low CD4 count, a ratio of CD4 to CD8 count of 0.47, and hypergammaglobulinaemia. He did not have any antibodies against diphtheria, tetanus, or poliovirus types 1 and 3, although he had been given diphtheria, tetanus, and pertussis and oral polio vaccines during his first year and a booster of the diphtheria, tetanus, and pertussis vaccine at 24 months. He had no clinical symptoms of AIDS, but his mother had AIDS and tuberculosis. CONCLUSION: Paralytic poliomyelitis in this child with HIV infection was caused by poliovirus type 2 after oral poliomyelitis vaccine. (+info)
User fees and drug pricing policies: a study at Harare Central Hospital, Zimbabwe.
In 1991, Zimbabwe introduced cost recovery measures as part of its programme of economic reforms, following a course taken by many developing countries. The system of user fees in public health care, aimed to 'protect and support the vulnerable groups' by exemption or incremental fees based on 4 income brackets. Drugs were charged at a percentage of the recommended retail price in the private sector. This study of 488 outpatients at a referral hospital in Harare examined how the new fee system functioned 6 months after its introduction. Patients were interviewed and their prescription records examined. Mean charges were determined for each fee category and revenue from drug charges was analyzed in relation to purchase cost to determine the gross profit. 31% of patients were exempted from all fees upon proof of monthly earnings of less than Z$150 (Z$5 = US$1). The remainder were classified into three fee-paying categories. The mean purchase cost for drug items was Z$3.89 per outpatient prescription. Outpatients paid a mean drug charge of Z$9.75 after exemption or discount. This was 2.5 times the cost price. The number of drug items obtained differed according to fee status: the fee-exempt category received a mean of 2.9 drug items compared with 1.9 drug items in the fee-paying categories. This difference originated at the point of prescribing. A number of practical problems in fee collection were noted. The drug pricing system generated high profit even after re-distribution to low-income users. This was attributed to economical and rationalized public sector drug procurement. Observation indicated that a proportion of the vulnerable were not effectively protected due to stringent requirements for proof of income. Appraisal of the fee policy indicated the need for more effective cross-subsidy and better administrative procedures; fee revenue should be directed towards improvement in quality of service. (+info)
To contract or not to contract? Issues for low and middle income countries.
Many low and middle income countries have inherited publicly funded and provided health services, often operating at relatively low levels of technical efficiency. Changing ideas about the management of the public sector, in particular stemming from new public management theory, are spreading to these countries, whether directly or via the recommendations of multilateral and bilateral aid agencies. Pronouncements of agencies such as the World Bank imply that competitive contracting with the private sector is likely to improve the efficiency of services provision. However, very little evidence is available on whether this is likely to be the case, and in what circumstances delivery of services through contracts with the private sector is likely to be preferable to direct provision by the public sector. This paper draws on evidence from five country case-studies of contractual arrangements, in Bombay, Papua New Guinea, South Africa, Thailand and Zimbabwe, done through collaborative research between the LSHTM Health Economics and Financing Programme and local researchers in each country. A common evaluative framework was applied in each country to selected, existing contractual arrangements. Services provided under contract and evaluated included catering, cleaning, security, diagnostic services and whole hospitals. Information is presented on the design of contracts, the process of agreeing contracts including the extent of competition, and the monitoring of contract performance. A variety of evidence, including information on the relative cost and quality of contracted out versus directly provided services in the case of South Africa, Thailand, and Bombay, is used to explore whether or not contracting out to the private sector represented a preferable means of service provision. This analysis, together with information on the capacity of the agency letting the contract, and on the wider environment including the level of development of the private sector, is used to identify which aspects of the contracting process and the context in which it takes place are important in influencing whether or not contracting with the private sector is a desirable means of service provision. (+info)
Serum level of maternal human immunodeficiency virus (HIV) RNA, infant mortality, and vertical transmission of HIV in Zimbabwe.
Maternal human immunodeficiency virus (HIV) RNA load, vertical transmission of subtype C HIV, and infant mortality were examined in 251 HIV-seropositive women and their infants in Zimbabwe. Demographic characteristics, health and medical histories, serum HIV RNA loads, and CD4+ lymphocyte counts for mothers were examined by logistic regression analysis to determine significant risk factors and their odds ratios for transmission and infant mortality. Tenfold (1 log10) incremental increases in maternal HIV RNA were associated with a 1.9-fold increase (95% confidence interval [CI], 1.2-2.9) in transmission and a 2.1-fold increase (95% CI, 1.3-3.5) in infant mortality (P<.01). Maternal CD4 cell counts and demographic and medical characteristics were not significant predictors of transmission. However, maternal CD4 cell counts below the median (400/mm3) were significantly associated with infant mortality (P=. 035, Fisher's exact test). The maternal level of serum HIV is an important determinant of vertical transmission and infant mortality in subtype C infection in Zimbabwe. (+info)
Zimbabwe's hospital referral system: does it work?
BACKGROUND: Anecdotal evidence has suggested inefficiency in the pyramidal health care referral system established in Zimbabwe in 1980, as part of its primary health care (PHC) model. AIM: To assess the functioning of the pyramidal referral system in two rural districts surrounding Harare, Zimbabwe, with regard to two common indicator conditions: pneumonia in children and malaria in adults. METHODS: For a three-month period, all complete inpatient records with discharge diagnoses of pneumonia or malaria from three hospitals representing different levels of care were analyzed (n = 227). Data were collected on demographic and patient care variables. The appropriateness of admissions and referrals was determined by an assessment of the severity of illness and 'intensiveness' of care required. Data were analyzed for differences among the three hospitals and between the two indicator conditions. Per night inpatient bed costs for each hospital were also calculated. RESULTS: For pneumonia in children, 56.8% of patients admitted at the secondary level, 53.8% of patients at the tertiary level and 57.8% of patients at the quaternary level were of mild severity. For malaria in adults, 74.0% of patients seen at the secondary level, 81.5% of patients at the tertiary level and 54.3% at the quaternary level were of mild severity. For pneumonia, were no differences in severity between the three hospitals whereas for malaria significant case-mix differences among the hospitals were found. Most patients attending the highest level referral facility were inappropriate admissions who could have been treated at a lower level of care. The majority of patients at all the hospitals studied had used that hospital as their first or second point of contact with the health services. There were large variations in the inpatient per night bed costs between the three hospitals. CONCLUSIONS: Using the indicator diseases of pneumonia in children and malaria in adults, this study concluded that this network did not meet design expectations as the central level referral hospital cared for a similar case-mix of patients as the district level, but at six times the cost. The appropriateness of admissions and referrals could be improved by developing or strengthening intermediate level facilities, by changing mechanisms of access to specialist facilities and by training health professionals in community settings. (+info)
Aggregation and distribution of strains in microparasites.
Recent research has shown that many parasite populations are made up of a number of epidemiologically distinct strains or genotypes. The implications of strain structure or genetic diversity for parasite population dynamics are still uncertain, partly because there is no coherent framework for the interpretation of field data. Here, we present an analysis of four published data sets for vector-borne microparasite infections where strains or genotypes have been distinguished: serotypes of African horse sickness (AHS) in zebra; types of Nannomonas trypanosomes in tsetse flies; parasite-induced erythrocyte surface antigen (PIESA) based isolates of Plasmodium falciparum malaria in humans, and the merozoite surface protein 2 gene (MSP-2) alleles of P. falciparum in humans and in anopheline mosquitoes. For each data set we consider the distribution of strains or types among hosts and any pairwise associations between strains or types. Where host age data are available we also compare age-prevalence relationships and estimates of the force of infection. Multiple infections of hosts are common and for most data sets infections have an aggregated distribution among hosts with a tendency towards positive associations between certain strains or types. These patterns could result from interactions (facilitation) between strains or types, or they could reflect patterns of contact between hosts and vectors. We use a mathematical model to illustrate the impact of host-vector contact patterns, finding that even if contact is random there may still be significant aggregation in parasite distributions. This effect is enhanced if there is non-random contact or other heterogeneities between hosts, vectors or parasites. In practice, different strains or types also have different forces of infection. We anticipate that aggregated distributions and positive associations between microparasite strains or types will be extremely common. (+info)