The institutional aspects of health sector reform: whither primary care? [abstract]

In recent years, there has been a great deal of discussion about the need for health sector reform. Most of the general discussions have centred around the need for ensuring equity, efficiency, effectiveness and quality, financial sustainability and intersectoral action and community participation. In practice, however, the large majority of the official efforts have focussed on health finance reform, as the several governments in the region have sought to cope with what has been defined as the health resource gap: that is, the difference between available revenues and rising health costs. In addition, the focus of most reform efforts has largely been on improving the health delivery systems. So far, there has been insufficient attention given to those factors affecting the demand for health and health care. Since one of these factors is likely to be the reform package itself, it is critical to seek to assess and evaluate the impacts of the reforms implemented. In this paper, it will be argued that socio-economic circumstances, as well as particular health finance reforms may be significantly changing the character of the demands for health care. It will be also suggested that to the extent that the inefficiency and ineffectiveness of the primary health care system has negatively contributed to the changing character of health demands, it may be necessary to raise questions about the current locus, viability and strength of the ideals of the primary care approach to health care. In this discussion, case material and data from selected countries in the Caribbean will be presented. (AU)

Chronic diseases: the new epidemic

Mortality statistics show that there has been a significant change in the leading causes of death in Jamaica over the last 50 years, characterized by a decrease in the infectious diseases and those due to undernutrition and an increase in the non-communicable disease. The various patterns of this epidemiological transition worldwide are outlined and the characteristics of this "new" epidemic are discussed. Data are presented from the findings of the recent multi-country study of hypertension and diabetes, including Jamaica, which shows that as the body mass index (BMI) increases across the African diaspora, so does the prevalence of hypertension and diabetes. Among the Jamaican population studied, the prevalence of hypertension was 19.1 percent among males and 28.2 percent among females. Reported prevalence of previously diagnosed diabetes was 5.3 percent in men and 10.4 percent in females. The gender differences are in part explained by the differences in mean BMI which were 23.8 and 27.9, respectively, for males and females. 30.6 percent of males and 64.7 percent of females were either overweight or obese, with obesity prevalent in 7.2 percent of the males and 31.5 percent of the females studied. The increasing prevalence of obesity across the Caribbean is cause for concern as it significantly impacts on the demand for health and medical care. The identification of these reversible risk factors should be used to inform public policy to tackle what will be a growing concern.(AU)

Patient satisfaction at health centres in Trinidad and Tobago

The aim of this paper is to identify background characteristics of health centre users in Trinidad and Tobago and their perceptions of the services provided. Multi-staged sampling was used to select 1,500 health centre users throughout the country. Data were obtained using structured interviews conducted on regular clinic days. Results show that there is an overwhelmingly large percentage of unemployed persons (80.4 percent) and women (75.9 percent) among the users of health centres. The elderly is well represented, with 25.4 percent of the sample being over 60 years of age. Also occupational status of family wage earners and educational attainment levels of respondents reflect a disproportionately higher number from lower socio-economic groupings among health centre users. On the other hand, proportions of different ethnic and religious groups among the respondents bear a striking similarity to the general population of Trinidad and Tobago. Respondents appear to be generally satisfied with the services of the health centres. When the categories for <

The need and demand for renal replacement therapy in ethnic minorities in England

STUDY OBJECTIVE: The study aimed to determine the relative risk of being accepted for renal replacement treatment of black and Asian populations compared with whites in relation to age, sex and underlying cause. The implications for population need for renal replacement therapy in these populations and for the development of renal services were also considered. DESIGN/SETTING: This was a cross sectional retrospective survey of all patients accept for renal replacement treatment in renal units in England in 1991 and 1992. PATIENTS: These comprised all 5901 patients resident in England with end-stage renal failure who had been accepted for renal replacement therapy in renal units in England and whose ethnic category was available form the units. Patients were catergorised as white, Asian, black, or other. Population denominators for the ethnic populations were taken from the 1991 census. The census categories Indian, Pakistani, and Bangladeshi were aggregated to form the denominator for Asian patients and black Caribbeans, black Africans, and black others were aggregated to form the denominator for black patients. MAIN RESULT: Altogether 7.7 percent of patients accepted were Asian and 4.7 percent were black; crude relative acceptance rates compared with whites were 3.5 and 3.2 respectively. Age sex specific relative acceptance ratios increased with age in both ethnic populations and were greater in females. Age standardised acceptance ratios were increased 4.2 and 3.7 times in Asian and black people respectively. The most common underlying cause in both these populations was diabetes; relative rates of acceptance for diabetic end-stage renal failure were 5.8 and 6.5 respectively. The European Dialysis and Transplant Association coding system was inaccurate for disaggregating non-insulin and insulin dependent forms. Unknown causes were an important category in Asians with a relative acceptance of rate 5.7. The relative rates were reduced only slightly when the comparison was confined to the district health authorities with large ethnic minority populations, suggesting that geographical access was not a major factor in the high rates for ethnic minorities. CONCLUSION: Acceptance rates for renal replacement treatment are increased significantly in Asian and black populations. Although data inaccuracies and access factors may contributed to these findings, the main reason is probably the higher incidence of end-stage renal failure.(AU)

Periodontal treatment needs in 12 and 15 to 19 year old school children in the Caribbean island of Antigua, 1990

A national survey was undertaken in 1990 to investigate the periodontal treatment needs in 12 and 15 to 19 year olds residing in urban and rural areas of Antigua. Using the CPITN procedure, examination of 246 12 year old children and 456 adolescents (15 to 19) revealed that the CPITN scores of healthy, gingival bleeding, calculus, 4 or 5 mm and >6mm periodontal pockets were distributed similarly in urban and rural areas. Calculus was the most commonly recorded score, with a prevalence of 46 percent in 12 year olds and 56 percent in 15 -19 year olds. 4 or 5 mm pockets were found in 14 percent of adolescents, affecting on average less than one sextant per subject, but deep pockets were uncommon, 26 percent of 12 year olds and 14 percent of adolescents had priodontally healthy mouths. Scaling and hygiene instructions were the predominant treatment needs in both age groups, but the requirement for complex periodontal care in adolescents was low - 3 percent. (AU)

Effects of user fees on the utilization pattern of family planning services in primary care centers in St. Elizabeth

Effective family planning services are critical to reducing fertility levels and increasing life expectancy. With declining donor support and the inability of public health resources to provide for all, the introduction of user fees - a cost recovery alternative was adopted. The study was conducted on 250 women 15-39 years in St. Elizabeth. The results indicate that although 49 percent women discontinued the use of contraceptives after the introduction of user fees, a similar proportion accepted a contraceptive method. More women, however, chose low cost contraceptives. Women are willing to pay for contraceptives based on their economic status; but concern exists for the under privileged who are unable to pay for a service which is so vital to the entire population. The need exists for strategies to be employed in the assessment of women, so that the poor can access these services free of cost, and for improving cost effective use of resources. The study points to the need for structured, ongoing family planning educational programmes focused on individual needs of both sexes. Formal education and employment opportunities could also play a major role in accessing family planning services. The search for alternate methods of financing such as private sector/community involvement, to supplement user fees, may be seen as another option (AU)

An assessment of the need for the dietitian in the management of patients with chronic noncommunicable diseases in primary health care in Cornwall County, Jamaica

Nutrition-related chronic noncommunicable diseases have emerged as one of the leading public health concerns of the last five decades. This problem is common in both developed and serveral developing countries with Jamaica as no exception. The aetiology and nature of these diseases render the level primary health care best suited for their management. Nutrition and dietary intervention is implicated if control in adult disability, morbidity and premature mortality from these diseases is to be realized. The report examines the nutritional assessment, information and counselling given to patients with common nutrition-related chronic noncommunicable disease at the level of primary care inthe country of Cornwall in Jamaica. The attitude of primary health care professional to the introduction of dietitian and their potential contribution. Seventy-seven health care recipients with chronic noncommunicable disease and 48 health care providers from four health centres were provided with questionnaires. The results which have been tabulated indicate hat although nutrition intervention is relatively frequent and done by individuals from a variety of health professions, it is deficient in the fundamental concepts and principles of nutrition and dietetics. However, a fair understanding of the nutritional care process seems to exist. The primary care health professional indicated a positive attitude towards the introduction of the dietitian. Seventy percent did not agree that nutrition education was primarily the duty of the dietitian. A number of conclusions were drawn from the study which formed the basis for the recommendations. (AU)

Service needs of children with disabilities in Jamaica

We investigated the service needs of children attending a medical assessment as part of a two stage survey of 2 to 9-year-old children in mid and south Clarendon, Jamaica. Parents were asked about symptoms relating to six different disabilities: visual, hearing, speech, motor, cognitive and fits. Following medical and psychological assessment, a diagnosis of mild, moderate, severe or no disability was made. For children with disabilities, the frequencies of five possible types of intervention recommended by the physician were analysed and related to the prevalence of the six disabilities in the parish. To estimate the needs of the Jamaican child population the figures were extrapolated based on an estimate of 1 million children under the age of 15 years. These needs were then compared with places in existing services. Of the disabled children, 62 percent needed special education, 29.5 percent needed community-based services, 21 percent needed spectacles, 21 percent needed specialist referral, and 6 percent required medical treatment. Although the vast majority of these needs are not met, many more could be met in the community if existing health and education personnel are trained in basic techniques of screening and assessment. (AU)

Training needs and services for elderly care in developing countries: models from Romania, Barbados and Kuwait

Developing countries are facing multiple problems in establishing and funding sociomedical services for the elderly. This study outlines the need for such services especially in the transitional stage of urbanization, changes in the structure and role of families, and the inadequate resources for establishing community-based elderly care programs. The study focuses on the analysis of human resource needs for training of the different categories of health workers, both educational degree and non-degree training for elderly care programs. It proposes an integrated approach for short-term training of physicians, nurses, and social workers. This concept was accepted and adopted by the Expert Group Meeting of the International Institute on Aging in Malta, 1989. This study also presents applications of this model in Romania, Barbados, and Kuwait. (AU)

Health and tourism in the Caribbean

Discusses the major concerns of how environmental matters affect tourist industry and how the industry might impact negatively on the environment, thereby creating a health hazard for all. Identifies priority issues as degradation of the coastal and marine environment, solid and liquid waste mangement and water quality and supply as crucial to tourism. Examines the behaviour related health problems associated with tourism; excess alcoholic consumption, sexually transmitted diseases and drug abuse and the ability of the health services to respond to these problems. Comments on the need for greater development of health tourism in the region and points to the need for Caribbean governments to collaborate in gathering more data on health and tourism (AU)

An economic model for nurse manpower planning in the Caribbean. Part 1: The issues

Below is a noneconomist's view on economic issues impacting on nurse manpower development in the Commonwealth Caribbean. The issues however are of an international nature and are therefore pertinent to all those interested in nurse manpower development. The main objective is to present a model for economic analysis and planning. (AU)