Cervical dysplasia treatment: key issues for developing countries

Many developing countries face serious obstacles that have hindered establishent of successful cervical cancer contrl programs. Various countries are now seeking to strenthen cytology services and identify simple low-cost screening strategies; but any real gains in reducing cervical cancer incidence and mortality will also require effective treatment of women with preinvasive disease. Despite a trend toward conservative outpatient approaches for treating cervical dysplasia in industrialized countries, clinicians in many developing countries still rely primarily on invasive inpatient methods such as cone biopsy and hysterectomy. For woment who could be treated with less invasive methods, these procedures tend to pose unnecessary risks and entail high costs that put them beyond the reach of may patients. Outpatient therapy, employing methods such as cryotherapy and the loop electrosurgical excision procedure (LEEP), combined with proper follow-up, is appropriate for dealing with visible lesions on the ectocervix when invasive cancer and endocervical involvement have been ruled out. Cryotherapy and LEEP hold out particular promise for developing countries because of their effectiveness, lack of side-effects, simplicity, and low cost. Cure rates range form 80 percent to 95 percent, depending on the method used and the severity of the lesions. However, each method has advantages and disadvantages that demand consideration. Various ways of reducing the number of follow-up visits, including the two-visit see and treat approach, are also available for use in areas where women's access to health services may be limited. A recent survey by the Program for Appropriate Technology in Health (PATH) affirmed the tendency to rely on cone biopsy and hysterectomy. It also found that in many places all degrees of preinvasive disease were treated, rather than only high-grade or severe conditions; that respondents in Latin America, the Caribbean, and Asia tended to use cryotherapy and LEEP more widely than other low-cost methods; the LEEP was preferred over cryotherapy in Latin America; and the colposcopes and other basic equipment needed to provide treatment were nto consistently or widely available in some settings (AU)

Improving financial management of health care in the Caribbean: conceptual and empirical issues

Structural adjustment is reducing the traditional dominant role of the state in the financing and provision of health care. Issues of equity, allocative efficiency, sustainability and clinical freedom are brought into question. This paper examines two models of escalating health costs and discusses the possibilities and limitations of cost sharing mainly health insurance), cost recovery (user fees) and cost containment (privatisation and decentalisation) measures in the health sector. It also explores additional measures to improve financial management in the health sector -- this must be seen as a moral oblication by all rather than a managerial imperative by a few (AU)

Some medical and economic implications of oxygen therapy - abstract

Oxygen is widely used in hospital practice. This paper documents critically its use in a 500-bed teaching hospital in Kingston, Jamaica. Three aspects of oxygen therapy were examined, namely, the prescription and administration of oxygen, the condition and maintenance of oxygen equipment and lastly the supplies of oxygen to the hospital. It was apparent that the same thought and precision normally accorded the prescribing of drugs was not exercised in the case of oxygen, which often seemed to be given as a routine measure. It was also noted that both medical and nursing staff were often unfamiliar with the performance of oxygen equipment and not always able to supervise its use. Little awareness of the likely inspired concentrations delivered by oxygen equipment was found. Much of the equipment used for oxygen therapy, including anaesthetic machines, was found to be defective and no regular preventive maintenance was being carried out. As a result, there was an enormous wastage of oxygen as well as deficient therapy. There was an enormous rise in the cost of oxygen. The cost of a 100-cubic foot oxygen was found to have increased from J$3.3 in 1977 to J$14.8 in 1984, and its transportation cost from the manufacturing plant to the hospital from J$1,000 to J$4,000 per month. Since the cost of oxygen is likely to rise even further, serious consideration should be given to the installation of oxygen concentrators or possibly to the use of industrial grade oxygen. In addition, there is clearly a need for further education in the use of oxygen and for improved maintenance and operation of equipment used for oxygen therapy (AU)