Undercover careseekers: simulated clients in the study of health provider behavior in developing countries.

The simulated client method (SCM) has been used for over 20 years to study health care provider behavior in a first-hand way while minimizing observation bias. In developing countries, it has proven useful in the study of physicians, drug retailers, and family planning services. In SCM, research assistants with fictitious case scenarios (or with stable conditions or a genuine interest in the services) visit providers and request their assistance. Providers are not aware that these clients are involved in research. Simulated clients later report on the events of their visit and these data are analyzed. This paper reviews 23 developing country studies of physician, drug retail, and family planning services in order to draw conclusions about (1) the advantages and limitations of the methods; (2) considerations for design and implementation of a simulated client study; (3) validity and reliability; and (4) ethical concerns. Examples are also drawn from industrialized countries, related methodologies, and non-health fields to illustrate the issues surrounding SCM. Based on this review, we conclude that the information gathered through the use of simulated clients is unique and valuable for managers, intervention planners and evaluators, social scientist, regulators, and others. Areas that need to be explored in future work with this method include: ways to ensure data validity and reliability; research on additional types of providers and health care needs; and adaptation of the technique for routine use.

Can licensed drug sellers contribute to safe motherhood? A survey of the treatment of pregnancy-related anaemia in Nepal.

Iron-deficiency anaemia is a major cause of maternal mortality worldwide, contributing to perhaps one in five maternal deaths. According to the World Health Organization (WHO), maternal anaemia is most severe in southern Asia. Drug retail shops frequently serve as the public's first point of contact for medical care, even though many drug sellers have no training in the treatment of illness. In western Nepal, drug retailer treatment of anaemia in pregnancy was investigated using interviews, focus groups and simulated clients ('surrogates'). Research assistants posing as the husbands of anaemic pregnant women asked retailers for advice. In 112 retail shops studied, 71% of the study surrogates were recommended iron supplements for purchase. Drug recommendations often included vitamins, minerals and other ingredients not therapeutic for pregnancy-related anaemia. Retailers were found to take little case history. Fifty-seven per cent of retailers asked about the duration of the pregnancy; 40% asked no relevant questions. Advice about the drugs sold was infrequent and 59% of the surrogates received no advice of any kind other than a product recommendation. Knowledge of important referral criteria was also especially low. Although 66% of the retailers had some sort of formal training for work with pharmaceuticals, current training levels were not found to be associated with better knowledge or practice. A focused training intervention to improve retailer treatment of anaemia in pregnant women is recommended.

The fall and rise of cost sharing in Kenya: the impact of phased implementation.

The combined effects of increasing demand for health services and declining real public resources have recently led many governments in the developing world to explore various health financing alternatives. Faced with a significant decline during the 1980s in its real per capita expenditures, the Kenya Ministry of Health (MOH) introduced a new cost sharing programme in December 1989. The programme was part of a comprehensive health financing strategy which also included social insurance, efficiency measures, and private sector development. Early implementation problems led to the suspension in September 1990 of the outpatient registration fee, the major revenue source at the time. In 1991, the Ministry initiated a programme of management improvement and gradual re-introduction of an outpatient fee, but this time as a treatment fee. The new programme was carried out in phases, beginning at the national and provincial levels and proceeding to the local level. The impact of these changes was assessed with national revenue collection reports, quality of care surveys in 6 purposively selected indicator districts, and time series analysis of monthly utilization in these same districts. In contrast to the significant fall in revenue experienced over the period of the initial programme, the later management improvements and fee adjustments resulted in steady increases in revenue. As a percentage of total non-staff expenditures, fiscal year 1993-1994 revenue is estimated to have been 37% at provincial general hospitals, 20% at smaller hospitals, and 21% at health centres. Roughly one third of total revenue is derived from national insurance claims. Quality of care measures, though in some respects improved with cost sharing, were in general somewhat mixed and inconsistent. The 1989 outpatient registration fee led to an average reduction in utilization of 27% at provincial hospitals, 45% at district hospitals, and 33% at health centres. In contrast, phased introduction of the outpatient treatment fee beginning in 1992, combined with somewhat broader exemptions, was associated with much smaller decreases in outpatient utilization. It is suggested that implementing user fees in phases by level of health facility is important to gain patient acceptance, to develop the requisite management systems, and to orient ministry staff to the new systems.

PIP: This analysis follows the evolution of Kenya's health financing policy reform program from 1989 to 1994 and judges the impact of the cost-sharing program on revenue, quality of health care, and use of outpatient facilities. The objectives of the cost-sharing program were to generate additional revenue to improve service quality, encourage cost-effective measures, and develop individual responsibility for health care. Problems due to the December 1989 implementation of cost sharing led to suspension of the outpatient fee in September 1990. In 1991, a technical assistance team uncovered specific areas in which problems occurred and determined that a successful reimplementation process would require a two-year phase-in. The new systems were introduced in a supervised manner following training workshops in the provincial hospitals. The original registration fee was reintroduced as a treatment fee, other fees were introduced, and some existing fees were adjusted. This analysis uses data from revenue generation, quality of care, and utilization impact to determine the impact of the program. It was determined that the cost sharing revenue generated by the new systems provided significant additional funding at the facility and district level. Funds have generally been used in a more appropriate manner than in the past, but patient perceptions of quality reveal inconsistencies among facilities. Unlike the reduction in use seen with the outpatient registration fee, the treatment fee resulted in only very modest decrease in use, with no downward trend noted at district hospitals. Lessons learned by comparing the initial implementation to the reimplementation include: 1) phasing the reimplementation over two years allowed testing and training, and beginning in referral hospitals was a good strategy, 2) allowing facilities to keep 75% of the revenue was a good strategy that was improved by the introduction of appropriate financial management systems, 3) a treatment fee is more acceptable than a registration fee, and 4) the use of revenue to improve quality has been compromised by a need to prevent deterioration in basic services as government allotments have fallen.

Drug retailer training: experiences from Nepal.

Sale of modern medicines by untrained peddlers, general merchants, and other drug sellers is common throughout the developing world. Drug sellers operating in the 'informal sector' are often the first source of health care outside the home. Reasons given by patients for using private drug sellers include expediency, convenience, efficacy of the medicines, dependability of supply, and reasonable cost. At the same time, self-medication through private drug sellers can be ineffective, wasteful, and at times distinctly harmful. Regulatory approaches to controlling drug selling in the informal sector, widely endorsed on paper through national drug control legislation, require a cadre of professional regulatory staff and enforcement mechanisms which are too often beyond the current economic and political reach of countries. In Nepal, where rugged terrain has limited infrastructure development, the doctor to population ratio is 1:23,000, utilization of government health services averages only 0.2 visits per person per year. Retail drug outlets outnumber health posts and health centers by a ratio of 4:1 and private drug sellers often offer the only access to modern medicine for much of the population. Community surveys have found that drug retailers are very often the first and only source of health care outside the home. Given the importance of retail drug outlets and the lack of trained pharmacists, the Department of Drug Administration in 1981 established a 45-hr course for drug retailers which emphasized practical training as well as formal teaching on pharmacology, ethics, storage of drugs, and legal issues. By the end of 1989, 4096 drug retailers had graduated from the course. Still run by the Ministry of Health Department of Drug Administration, the course has proven to be administratively feasible and has been quite popular with drug retailers. Initial reservations expressed by doctors and some pharmacists were soon overcome, and the course is now well accepted by professional groups. Because the course is offered in different locations, geographic coverage has also been very good despite Nepal's logistic constraints. The operating cost of the course averages about U.S. $18 per trainee. Informal evaluations have resulted in plans for refresher training more narrowly focused on safe dispensing and appropriate referral for a limited number of important public health problems. Since 50-90% of pharmaceutical expenditures typically pass through the informal private sector in developing countries, it is suggested that other countries consider focused drug retailer training as a response to the problems of manpower shortages and drug dispensing by unqualified staff.

Intervention research to promote clinically effective and economically efficient use of pharmaceuticals: the International Network for Rational Use of Drugs.

Despite acceptance of the essential drug concept by over 100 countries, current drug use patterns frequently result in unsafe use, waste of scarce resources, non-compliance, excess adverse drug reactions and disease resistance. Even in countries where resources for research are available, most efforts to improve drug prescribing have never been properly evaluated. Proposed interventions should reflect the behavioral basis for current drug use, target priority public health areas, and be feasible in developing country contexts. Most importantly, they must be critically assessed for cost and effectiveness in well-controlled field trials. The International Network for Rational Use of Drugs (INRUD) is a cooperative organization of health professionals and researchers in developing countries whose aim is to promote improved quality of care through more clinically effective and economically efficient use of pharmaceuticals. To accomplish this, INRUD will strengthen regional and national capacities to develop and scientifically evaluate programs to improve drug use and disseminate information on practical strategies shown to be cost-effective.

Setting the price of essential drugs: necessity and affordability.

A method has been developed for fine tuning the selection of drugs to improve cost recovery, to promote appropriate drug use, and to make more drugs more affordable. This scheme is based on a classification of drug necessity (vital, essential, non-essential) and on the relative cost of complete courses of treatment so that expensive drugs can be subsidised by marking up inexpensive ones.

Effectiveness of open-circuit and oxyhood delivery of helium-oxygen.

The combination of helium with oxygen is less dense than air and as such has been beneficial to patients with airflow obstruction within the large airways. The purpose of this study was to evaluate the effectiveness of delivering He-O2 by open-circuit systems by measuring DD50 in five adult volunteers. The mean (+/- SD) DD50 with a nonrebreathing mask was 1.32 +/- 0.89, with a simple mask was 1.21 +/- 0.87, and with a nasal cannula was 1.00 +/- 0.13; the DD50 with the nonrebreathing mask and the simple mask was statistically greater than with the cannula (p less than 0.05). Two infant oxygen hoods were assessed by measuring the nitrogen concentration at different locations in the hoods. The N2 concentration increased progressively from top to bottom, indicating that the helium was concentrated at the top. We conclude that the nonrebreathing mask and simple masks are probably satisfactory He-O2 delivery systems, that the infant oxyhood may be suboptimal, and that the nasal cannula is ineffective.

Revolving drug funds: conducting business in the public sector.

Pharmaceuticals are essential for preventive and therapeutic health services. Unfortunately, significant demand, limited funds and high prices contribute to frequent shortages of drugs in many public health programs. One method for financing pharmaceutical supplies has been the establishment of revolving drug funds (RDFs) in which, after an initial capital investment, drug supplies are replenished with monies collected from the sale of drugs. All too often however, the funds actually recovered are insufficient to replenish supplies and the fund is soon depleted. In this paper we consider the potential benefits and common pitfalls of revolving drug funds and then focus on the central role of financial planning in establishing drug sales programs. Experiences from a variety of countries suggest several causes for the failure of some RDFs, including: under-estimation of capitalization costs, prices set below true replacement cost, frequent failure to collect payment, delays in cash flow which make funds unavailable for replenishment of drug stocks, rapid program expansion for which additional capital funds are not available, losses due to theft and deterioration of drugs, unanticipated price increases due to inflation or changes in parity rates and foreign exchange purchase restrictions. Common to many of these problems is the lack of a businesslike orientation to RDFs and, in particular, lack of careful financial planning and management. Financial planning for an RDF includes four analytical tasks: assessment of the potential market, estimation of the costs of an RDF, establishment of the cost-recovery objectives, definition of the role of subsidies and surcharges.(ABSTRACT TRUNCATED AT 250 WORDS)

Health administration can be stressful ... but not necessarily distressful.

Stress is the natural response to personal and organizational demands. It is manifested in elevated heart rate, respiration, blood pressure, and adrenaline in the blood. It is not something over which we have conscious control. Stress has both beneficial and destructive consequences. It is the destructive consequences with which we are the most familiar. These include tension, cardiovascular diseases, peptic ulcers, sexual dysfunctions, and depression. These are the undesirable consequences of stress; they constitute distress. They are not an inevitable consequence of stressful events. The purpose of this article is to discuss the unique demands of hospital administration and several methods of preventive stress management. There are no universal ways to prevent or treat distress. Preventive stress management and treatment aimed at increasing healthy stress and preventing distress must be established by each particular hospital or administrator interested in creating a healthy work environment.

Decision-making among emergency room residents: preliminary observations and a decision model.

Emergency room residents face a range of clinical decisions and often call on senior residents or faculty members for help. The individual clinical decision process has frequently been analyzed, but little attention has been given to the social process in clinical decision-making. Based on data from interviews and over 100 hours of direct observation at two large urban general hospitals with busy emergency rooms staffed by medical and surgical residents, the authors suggest there are five basic decision situations. In each situation, the residents appeared to follow implicit decision patterns about involving other medical and surgical staff in the final clinical decision. The decision situations are nonacute, routine acute, nonroutine acute, multispecialty acute, and crisis. These situations call for individual, consultive, or consensual patterns in making decisions. The consequences of these patterns are explored. Improving residents' decision-making should contribute to improved understanding of the resident's role, better resident supervision, and better emergency room functioning.

Applying management science in developing countries: ABC analysis to plan public drug procurement.

Despite the vital role of pharmaceuticals in the prevention and treatment of major causes of death and disability in the developing world, high costs and frequent shortages remain chronic problems for drug supply programs. Yet, management techniques developed to optimize the use of scarce resources have had limited application in the settings of greatest need. An important determinant of the cost and supply of drugs is the procurement pattern. This study reviews procurement patterns in selected public supply programs and, using management science techniques, compares alternative procurement patterns in terms of inventory costs and shortages. Using drug cost and quantity estimates from two countries, a simulated ABC analysis was performed. This analysis showed drug inventories to be typical of industrial inventories: Over 80% of the consumption in dollars was accounted for by less than 20% of the drugs. Procurement patterns with more frequent purchasing or delivery of high usage drugs could reduce average inventories 20-50% over the commonly observed annual purchasing pattern. Sensitivity analysis of the results confirmed that variability in the delivery time and consumption pattern has a significant impact on the efficiency and economy of a procurement system. Closer supplier monitoring and better forecasting should reduce this variability.

Prenatal care and pregnancy outcome in an HMO and general population: a multivariate cohort analysis.

We studied the use of prenatal care and pregnancy outcome in 4,148 deliveries among members of a well-established health maintenance organization (HMO) and 19,116 births among the 1973-1974 White birth cohort in the Portland, Oregon area. Mothers in the HMO were almost one year older on the average, slightly better educated, and less frequently unmarried, but had virtually identical past pregnancy histories when compared with the general population cohort. HMO members began prenatal care one month later and had three fewer visits than the general population (p less than .01); 78 per cent of the general population and only 64 per cent of HMO members began prenatal care in the first trimester (p less than .01). With maternal risk held constant, low birthweight, neonatal mortality, and infant mortality were 1.5 to 5 times greater with late, less frequent prenatal care than with early, frequent care. Multivariate analysis demonstrated a positive relationship between prenatal care and birthweight. Although this relationship was independent of risk factors recorded on birth certificates, it is not necessarily a causal relationship. Unadjusted prematurity, neonatal and infant mortality rates did not differ between the HMO and general populations. Multivariate analyses indicated that, independent of all maternal risk factors, HMO membership was associated with an increase of 30 grams in the predicted birthweight (P less than .01), but had no effect on mortality. The data suggest that, in Portland, Oregon, pregnancy outcome for HMO members is comparable to that of the general population.

Liberalized abortion in Oregon: effects on fertility, prematurity, fetal death, and infant death.

An analysis of Oregon Vital Statistics data from 1965 to 1975 was conducted to assess the impact of Oregon's 1969 abortion legislation, which substantially increased the number of reported medically induced abortions. This increase was associated with a slight increase in the age-adjusted 1970 fertility rate and there was no decrease in births to women in the age groups obtaining proportionately the most abortions. A significant and persistent 11 per cent reduction in premature births to women over age 20 (p less than .001) and a 22 per cent reduction in spontaneous fetal deaths (p less than .05) were associated with liberalized abortion. Decreases in neonatal and postneonatal infant mortality were observed, but were indistinguishable from an ongoing trend toward improved infant health. A gradual 25 per cent decline in the age-adjusted fertility rate occurred between 1969 and 1975, but the increase in the number of reported abortions could account for only one-fourth of this decrease. A seven-fold increase in the use of family planning clinics between 1970 and 1973 and more liberalized laws regarding provision of family planning service appeared to account for a much higher proportion of the decreased fertility than did liberalized abortion.