Can intensive campaigns dynamize front line health services? The evaluation of an immunization campaign in Thiès health district, Senegal.

With the aid of UNICEF, Senegal has implemented an intensive national vaccination campaign, the first phase of which extended over 4.5 months in 1986 and 1987, the second and third phases being held exactly 1 and 2 years later. The present article evaluates its effects in Thiès health district. It seeks to establish; whether the objectives of the campaign were achieved and maintained beyond the intensive phase; whether the organization of the campaign was appropriate and did dynamize the first-line health services. The low sustainability, the interference with other activities of the services and some technical deficiencies are shown. They are related to the managerial characteristics of an intensive campaign. The conclusions of this evaluation question (1) the possibility of developing basic health services under one or two programs, (2) the appropriateness of 'Universal Child Immunization in 1990' and (3) the value of accelerating immunization activities when no epidemics occur. Two types of alternatives are suggested: technical options to improve UCI sustainability, and a reorientation of health policy that advocates district management and the administrative as well as operational integration of vertical programs.

Selective primary health care: a critical review of methods and results.

In the aftermath of the Alma Ata conference, three types of Primary Health Care (PHC), have been identified. Comprehensive PHC (CPHC) and Basic PHC (BPHC) both have a wide scope of activities, BPHC however does not include water and sanitation activities. Only one year after the Alma Ata conference, CPHC was attacked as not 'feasible' and selective PHC (SPHC) was offered as an interim alternative. SPHC only addresses 5 to 8 diseases, almost all of them falling within the realm of pediatrics. Our article critically analyses the methods and results of SPHC. It contrasts the lack of supportive data for SPHC and its methodological deficiencies with the extent of its adoption by bilateral cooperation agencies, foundations, academic and research institutions, and international agencies. We suggest that rather than health factors, the major determinants of this adoption have been political and economical constraints acting upon decision makers exposed to a similar training in public health.

Prospective epidemiologic survey of patients with community-acquired pneumonia requiring hospitalization in Switzerland.

BACKGROUND: Community-acquired pneumonia (CAP) is a common problem and the principal infection requiring hospitalization, but its treatment is complicated by the difficulty in microbiological diagnosis and the increasing incidence of antibiotic resistance among respiratory pathogens. The purpose of this paper is to present the main epidemiologic features of patients with CAP requiring hospitalization in our country. METHODS: We enrolled three hundred and eighteen adult patients with CAP requiring hospitalization in seven large medical centers in Switzerland during two winter periods. The patients' mean age was 70.4 years. This study describes the epidemiology of these patients. Clinical, radiologic and microbiological evaluations were performed at study entry during treatment, and at 4 weeks post-therapy. For microbiological diagnostic purposes, sputum culture, throat swab culture, PCR, blood cultures, Legionella urinary antigen and serologic evaluations were also performed. RESULTS: Despite the higher mean age, the overall mortality rate was 8%, lower than in other comparable studies. The most common underlying diseases present at study entry were cardiac failure (23%), chronic obstructive pulmonary disease (20%), renal failure (15%), and diabetes (12%); 40% of the patients were smokers. Although dyspnea, cough and positive pulmonary auscultation findings were present in about 90% of patients, fever >38 degrees C was present in only 64%. The most frequently isolated respiratory pathogens were Streptococcus pneumoniae (12.6%), Haemophilus influenzae (6%), Staphylococcus aureus (1.6%), and Moraxella catarrhalis (1.6%). Atypical pathogens were frequently found, with the following distribution: Mycoplasma pneumoniae, 7.5%; Chlamydia pneumoniae, 5.3%; and Legionella pneumophila, 4.4%. The mean duration between onset of symptoms and hospital admission was 4.8 days, and the mean treatment duration was 12.1 days. Two weeks after the start of therapy, although clinical symptoms were absent, radiologic infiltrates were still present in 24% of patients. CONCLUSIONS: The microbiological diagnosis in CAP can be established in only about 50% of cases with the combination of several diagnostic tools. Epidemiologic surveys of CAP should be performed on a regular basis, regionally, as a way to improve the management of these infections.

Epidemiology's contribution to health service management and planning in developing countries: a missing link.

Two hypotheses are examined in the light of experience and the literature: (1) health service planning requires little epidemiological information, and (2) health services rarely get useful answers to relevant epidemiological questions. In the first hypothesis, the theoretical robustness of the concept of a minimum package of activities common to all facilities belonging to the same level of the system and the extent to which it is unaffected by variations in the frequencies of most diseases are examined. Semi-quantitative analyses and analysis of routine entries and participation suffice to adapt this package to the local context. Some of the methods which give a fundamental role to epidemiological information are criticized. With regard to the second hypothesis, the pertinent contributions epidemiology may make to health service organization are reviewed. These include identification of diseases that justify special activities (health maps and interepidemic surveillance), determination of the activities that should be added to the health centres, the political usefulness of rare impact assessments, and the relevant demographic elements. Finally an epidemiological agenda is proposed for specialized centres, districts, universities, and the central decision-making level of health ministries in developing countries.

PIP: The many epidemiologic publications that address specialized programs differ with the scarcity of relevant information for health centers and general hospitals. Health service officials in developing countries are more likely to manage health centers and general hospitals than specialized programs. Two public health researchers examine two hypotheses to demonstrate how epidemiology might become more useful to health service management and planning in developing countries. The first hypothesis is that health service planning requires little epidemiological information. The researchers suggest that health services operating in an integrated health system in which each level has its own tasks, the levels' infrastructures are uniform, and each level has a defined minimum activities package (MAP) can operate correctly without much epidemiological information. They show that the epidemiological approach to planning (e.g., CENDES method) has conceptual flaws. The second hypothesis is that health services rarely get useful answers to relevant epidemiological questions. The researchers examine identification of diseases that justify special activities (e.g., health maps), determination of the activities that should be added to the health centers, the political usefulness of rare impact assessments, and the relevant demographic elements as possible contributions that epidemiology may offer health services. They propose that epidemiological activities be centralized. At the district level, all health centers should conduct epidemiological monitoring of 2-3 diseases requiring rapid intervention. A regional unit should process information collected by the health centers and from other ministries, conduct investigations of outbreaks, and supervise the quantitative work performed at the district level. The central level of the Ministry of Health should coordinate and direct the work of the research units (e.g., university's epidemiology department and a specialized clinic) and supervise and evaluate the regional units, centralize information, and participate in the planning and programming divisions' work.

Principles of health infrastructure planning in less developed countries.

This article proposes a number of key principles for health infrastructure planning, based on a literature review on the one hand, and on a process of internal deduction on the other. The principles discussed are the following: an integrated health system; a thrifty planning of tiers within that health system; a specificity of tiers; a homogeneity of the tiers' structures; a minimum package of activities; a territorial responsibility and/or an explicit and discrete responsibility for a well-defined population; a necessary and sufficient population basis; a partial separation of administrative and public health planning bases; and, finally, rules for a geographical division and integration of non-governmental organizations. The definition of two strategies, primary health care and district health systems, is also revisited.

PIP: The authors propose some principles for health infrastructure planning, based upon a literature review and internal deduction. The following principles are discussed: an integrated health system, a thrifty planning of tiers within that health system, a specificity of tiers, a homogeneity of the tiers' structures, a minimum package of activities, a territorial responsibility and/or an explicit and discrete responsibility for a well-defined population, a necessary and sufficient population basis, a partial separation of administrative and public health planning bases, and rules for a geographical division and integration on nongovernmental organizations. The definitions of primary health care and district health systems are also revisited.

Through Mintzberg's glasses: a fresh look at the organization of ministries of health.

In 1987, district health care policies were officially adopted by a majority of developing countries. Many operational problems constraining implementation of such policies have subsequently been identified, most of which are attributable to well-known characteristics of less developed countries. However, the policy of operational and administrative decentralization has often been critically obstructed by inappropriate organizational structures in ministries of health. By applying Mintzberg's analytical framework to several ministries of health, we identify structural deficiencies that make systems unfit to match their policy environment and yield the expected outcomes of functional and decentralized services. We propose a typology likely to elicit strategies for decentralizing health care administration. Our analysis is based on the following steps: a description of Mintzberg's concepts of organizational structure, generic components (strategic apex, technostructure, supporting structure, middle line, operational core) and functions (horizontal and vertical integration, liaison devices, vertical and horizontal decentralization) applied to health systems; a discussion of divisionalized adhocracy as a suitable configuration for health organizations with a need for a high degree of regional autonomy, community participation, medical staff initiative, action research and operational research, and continuous evaluation; a discussion of the organizational features of a number of health ministry systems and a consideration of strategies for transforming configurations towards divisionalized adhocracy.

Senegal moves nearer the goals of Alma-Ata.

PIP: In Senegal, the Thies project adopted a new approach to defining and putting health development strategies in effect for each district. This is in response to the Alma-Ata Conference which advocated comprehensive primary health care (PHC) in a development spirit. Health administration follows territorial divisions. 30 medical division cover the 30 departments and form 10 medical regions. The 1st level is the health post. In villages far from health posts, health huts have been set up. About 15 health posts are administered by a health center under a physician. A medical district is made up of many health posts, a health center, and the administrative structure. By 1984, the Ministry of Health wanted to improve the service quality and integrate the services into PHC, District medical officers (DMO) were trained in public health and health districts were organized. The teaching methods were based on the doctor's observations of local health services. The district chief medical officer is the only supervisor. But there is too much for 1 person to do. So, it was suggested that he should be the head of a coordinating team. After 2 years of the project, 25 of the 47 medical districts have a trained medical officer; 8 of the 10 regions do also. 6 of the 19 districts begun to take shape as an integrated system. There have been pilot projects which should serve as a model for the nation. However, general application of results has been slow. Training given an entry point into the health system. The project cost US$ 632,000 over 2 years, and gains have been made in basic PHC.^ieng

Likelihood ratios: a real improvement for clinical decision making?

The concept of likelihood ratio has been advocated for several years as one of the better means to evaluate diagnostic tests and as a practical and valuable tool in clinical decision making. In this paper we review the basic concepts underlying the evaluation of diagnostic tests and we explore the properties and usefulness of both positive and negative likelihood ratios compared with sensitivity and specificity. Particular attention is given to the use of likelihood ratios in the clinical setting. Likelihood ratios have three main advantages: they are intuitive, they simplify the predictive value calculation and the overall evaluation of sequential testing. Disadvantages are the non-linearity and the necessity to recalculate probabilities in odds. Although they summarize the information contained in sensitivity and specificity, these characteristics are still necessary for certain clinical decisions. Since likelihood ratios have been promoted among physicians and medical students, we discuss examples of inappropriate use and misunderstandings in the medical literature: the frequent omission of confidence intervals, the choice of cut-off points based on likelihood ratios for positive test results only and the confusion between likelihood ratios for ranges and those for cut-off points.

El Senegal se aproxima a los objetivos de Alma-Ata / Senegal moves nearer the goals of Alma-Ata

Proyecto del Senegal para ampliar la cobertura de atención primaria de salud, mejorarla cualitativamente mediante una acertada participación de la comunidad y organizarla como escalón de envío de casos

Senegal moves nearer the goals of Alma-Ata

A project in Senegal aims to extend the range and coverage of first-line health service activities, raise their quality, provide them with a readily available referral structure, and dynamize community involvement