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Cost effective method for diagnosis of catheter related sepsis

Dr.Ritesh Agarwal, Dr.Mahadevan Shriraam   (9 April 2004)

Improving diabetes care in the economically disadvantaged

Dr. Mahadevan Shriraam, Dr. Ritesh Agarwal   (9 April 2004)

Insulin Therapy in the ICU

Dr.Ritesh Agarwal, Dr.Mahadevan Shriraam   (15 April 2004)

Health care system needs to be restructured.

Anil Pandit   (17 April 2004)

Better surgical skills and cheaper innovations instead of expensive technological advances

Anuruddha M. Abeygunasekera   (1 May 2004)

“Take health into our own hands” – Community-based health insurance in Burkina Faso

Manuela De Allegri, Bocar Kouyaté, Rainer Sauerborn (see text for affiliations)   (6 May 2004)

Learning from developing countries.

Prakash C. Das, The Netherlands   (7 May 2004)

Controlling the cholera epidemic in Peru: The community’s Oral Rehydration Units

Walter H. Curioso, J. Jaime Miranda, Ann Marie Kimball   (8 May 2004)

Health districts in Western Europe: the Belgian local health systems project

Jean-Pierre Unger, Bart Criel, Jean Van der Vennet, Sylvie Dugas, Patricia Ghilbert, Pierre De Paepe, Michel Roland   (13 May 2004)

Learning from the developing world: sources of information

James N Newell, Andrew S Furber   (20 May 2004)

Learning from developing countries - Neighbourhood Network in Palliative Care – An innovative experiment in Long Term care (LTC) and Palliative Care (PC):

Suresh Kumar   (1 September 2004)

Learning from less developed countries: From rural hygiene to strengthening peace

Stella Fatovic-Ferencic, Željko Dugac MD PhD   (21 September 2004)

Learning for the betterment

Kaushal R Pandey   (22 September 2004)

Measuring Quality of Care in a District Hospital – using a Lot Quality Assurance Sample of In-patient Records

Bernhard Gaede   (28 September 2004)

Fostering public-private partnerships for non-communicable diseases – a beginning

Sania Nishtar   (28 September 2004)

developing world medicine

peter blackwell-smyth, kim hinshaw. Michael Breen   (29 September 2004)

Seek an improved balance between system and community

Masamine Jimba, Susumu Wakai   (7 October 2004)

A Cardiovascular Risk Awareness Clinic in Rural India

Shakuntala Chockalingam   (13 October 2004)

Health information network of Cuba (INFOMED): applying information technology under adverse constraints

Luis C Silva, Pedro Urra   (2 November 2004)

Learning from the developing world: partnerships in child and adolescent mental health

Nisha Dogra, Olayinka O Omigbodun   (2 November 2004)

Cost effective method for diagnosis of catheter related sepsis 9 April 2004
Dr.Ritesh Agarwal, DM fellow Pulmonary Medicine & Critical care PGIMER, Chandigarh, India 160012, Dr.Mahadevan Shriraam Send response to journal: Re: Cost effective method for diagnosis of catheter related sepsis	CRBSI (Catheter related blood stream infection) is defined as a blood stream infection due to an organism that has colonized a vascular catheter. Diagnosis of CRBSI in the modern ICUs would include simultaneously collected quantitative blood cultures in which the number of microbes isolated from blood obtained through a Central venous catheter (CVC) is atleast 5- fold greater than that from a peripheral blood culture or simultaneous quantitative blood cultures drawn from CVC and the peripheral vein in which growth is detected from the blood drawn from the CVC atleast two hours earlier than a simultaneously drawn blood cultured from a peripheral vein, so called, differential time to positivity or an endoluminal brush technique. In the absence of quantitative cultures in our center, a more conservative approach which is followed at our centre is as follows. In patients with suspected CRBSI and severe sepsis, blood cultures from central venous catheter and from a peripheral vein is sent, parenteral antibiotics are started. The catheter is removed and sent for culture. On the other hand, in patients who have only fever with no localizing signs, blood cultures from central venous catheter and peripheral vein is sent, CVC is replaced over a guide wire and sent for culture. CRBSI is diagnosed if both cultures from both CVC as well as peripheral vein are positive for the same organism or if the CVC tip grows an organism. Thus we are able to diagnose CRBSI as effectively as in the west without the need for sophisticated techniques. 1. Rijnders BJA, Wijngaerden EV, Peetermans WE. Catheter-tip colonization as a surrogate end point in clinical studies on catheter-related blood stream infection: How strong is the evidence? Clin Infect Dis 2002; 36: 131. 2. Beutz M, Sherman G, Mayfield J, Fraser VJ, Kollef MH. Clinical utility of blood cultures drawn from central vein catheters and peripheral venipuncture in critically ill medical patients. Chest 2003; 123:854. Competing interests: None declared
Improving diabetes care in the economically disadvantaged 9 April 2004
Dr. Mahadevan Shriraam, DM fellow (Endocrinology) PGIMER, Chandigarh, India 160012, Dr. Ritesh Agarwal Send response to journal: Re: Improving diabetes care in the economically disadvantaged	With respect to diabetes care, we know that patients with Type 1 Diabetes mellitus require insulin for survival. In the west, human insulin is the only available insulin and is considered the standard of care and bovine/porcine insulin use is out of vogue. However, it is clear from the available literature that bovine insulin is as effective as any other species of insulin with no extra adverse effects. Bovine insulin (atleast the one marketed by one of the major pharmaceuticals) is available at half the cost of human insulin in our country and is the most frequently used insulin in our centre for the economically disadvantaged. Thus our poorer patients get the same benefit at half the price. Also, refrigeration of insulin is recommended for long term use. Many of our patients do not have the facility for the same and one indigenous technique which we have been following is storing the insulin in earthen potware filled with water and surrounded by mud. This is a natural method of bringing down the temperature and preserving the efficacy of insulin. No significant difference in clinical efficacy has been noted by us. Competing interests: None declared
Insulin Therapy in the ICU 15 April 2004
Dr.Ritesh Agarwal, DM fellow (Pulmonary Medicine & Critical care) PGIMER, Chandigarh, India 160012, Dr.Mahadevan Shriraam Send response to journal: Re: Insulin Therapy in the ICU	Sepsis is amongst the most common causes for admission in the intensive care unit (ICU). Despite numerous advances made in the field of medicine, the mortality of sepsis remained unchanged at 30-40% for the past 3-4 decades. Recent advances in the management of sepsis like activated Protein C, early goal directed therapy, low dose glucocorticoid therapy and intensive euglycemic control have brought a decrease in the mortality associated with sepsis. Of these a strategy which can be easily and readily implemented in the ICU is the intensive euglycemic control. It not only improves survival but also decreases bloodstream infections, acute renal failure requiring dialysis or hemofiltration, red-cell transfusions, critical-illness polyneuropathy and overall ICU stay. However this strategy requires hourly blood glucose monitoring which costs approximately 600 rupees a day. This adds on to the expenses of the patient, which is already very high for a patient who is admitted in the ICU. To decrease this, a strategy which we follow in our ICU is that we maintain a blood glucose level between 80-150 mg%. To achieve this, we give the patient 2 doses of intermediate acting insulin twice a day along with sliding scale insulin in 4 hourly doses. This has decreased the cost to almost one-fourth and has given us glycemic control as desired. Competing interests: None declared
Health care system needs to be restructured. 17 April 2004
Anil Pandit, Resident Patan Hospital, Lalitpur, Nepal , GPO 252, Kathmandu Send response to journal: Re: Health care system needs to be restructured.	Preventable infectious diseases are still major killers in developing world. Acute respiratory illness, diarrhoea, and neonatal infections still remain major killer in children. India has the second highest burden of HIV and AIDS in the world with 4.58 million people being infected with HIV1. Rampant use of antibiotics has up-surged newer problem of antibiotic resistance to very common problems like enteric fever, malaria, and other infectious diseases. Improved primary health care, living standards and adoption of Western life style has caused increased incidence of non-communicable diseases. India has higher number of people with diabetes than any other country in the world2. The average life span of Indians has increased from 32 years a few decades ago to nearly 65 years. In India 52% of cardiovascular deaths occur below age of 70, compared with 23% in countries with established market economies2. The problem of both infectious and non-infectious disease is in rise in developing world giving us chaotic picture of diseased world. The health care system of developing countries, however, is built to manage infectious diseases. Improving nutrition, immunization and sanitation are deserved priorities than managing chronic non-communicable diseases like coronary artery diseases and diabetes mellitus. With swiftly changing demographics in developing world like increase in life expectancy and adoption of Western life style, the incidence of cardiovascular diseases, diabetes, hypertension, road traffic accidents and cancers are increasing. However, health care professionals and health policy makers are unable to address this problem either of ignorance or lack of resources. Treating non-communicable and chronic diseases are always more expensive than treating infectious diseases. The health care professionals in developing countries have always suffered. Increasing clinical work load, poor-pay, scarce continuing medical education, limited resources in difficult circumstances, and poor interaction with health policy makers are some of the major constraints in which we have to work. Investing towards re-structuring present health care system in developing countries seems to be immediate need. Public health program should be targeted to address both the communicable and non-communicable diseases. The especial attention should be focussed for non-communicable diseases, which if not prevented early, is going to be a major epidemic. Reference 1. Zaidi A K M, Awasthi A, deSilva H J.Burden of Infectious diseases in South Asia.BMJ.2004.328.811-15 2. Ghaffar A, Reddy KS, Singhi M.Burden of Non-communicable diseases in South Asia.BMJ.2004.328.808-10. Competing interests: None declared
Better surgical skills and cheaper innovations instead of expensive technological advances 1 May 2004
Anuruddha M. Abeygunasekera, Urological Surgeon Teaching Hospital, Galle, Sri Lanka. Send response to journal: Re: Better surgical skills and cheaper innovations instead of expensive technological advances	Compared to the developed world there are many differences in the surgical services in the developing world. High patient load, limited resources, advanced stage of diseases at presentation and limited number of cosultant surgeons ( mainly as a result of migration to the developed world!) are some obvious diiferences. Although these have a negative impact on surgical care there are some inherent advantages of these unfavourable factors too. these include more opportunities to develop surgical skills, less litigation allowing bold decision making, ability to survive without practising defensive medicine and more commitment from patients in the battle against illnesses. Although there is hardly ant support for academic medicine and research in the developing world, lack of resources and high case load promote new thinking and improvisations. I wish to describe two examples from my experience to illustrate my point. While much of the surgical pathology seen in the developing world is similar to that seen in developed countries, the challenge is to manage these problems with limited resources. For example while transurethral resection of the prostate (TURP) is widely performed in the Western world, open suprapubic prostatectomy remains the gold standard in the developing world, where glycine containing irrigant solutuions are difficult to come by (1). However we use sterile water, prepared locally at the hospital, as the irrigant fluid and perform TURP. To avoid TURP syndrome due to absorption of water, resection time is limited to 30 minutes. The prostate glands that are too large to be resected completely within 30 minutes are subjected to a second operation in 4 to 6 weeks. According to this protocol we have performed 362 TURPs during a period of 36 months.Indications for surgery were acute urinary retention in 195 (54%) patients, lower urinary tract symptoms in 118 (33%) patients and chronic urinary retention in 49 (13%) patients. 148 (41%) patients were over the age of 70 years. Twelve (3%) patients underwent a second operation to complete the resection. There were no postoperative deaths. Four (%) patients required postoperative care in the intensive care unit. One each for bronchospasm and myocardial infarction and two for close monitoring as there was a high risk for a cardiac event.Four (1%) patients were given a single dose of frusemide postoperatively for suspected TURP syndrome although there was no biochemical evidence to confirm it. Twenty-nine (8%) patients were given intra or postoperative blood transfusions. Histopathology of prostatic chips revealed malignancy in 31 (9%) patients. At 3 months after surgery all patients were voiding urethrally with no threat to renal function.When copared to results of TURP in the developed world, TURP done using water as the irrigant fluid appears to be an acceptable alternative in resource-poor settings (2). Clean intermittent catheterisation (CIC) is a simple, safe and effective way of managing patients with neurogenic bladder dysfunction and preventing re-stenosis after endoscopic surgery for urethral stricture disease. Both these conditions are common in Sri Lanka. Pelvic and spinal trauma is common due to fall from trees, road traffic accidents and war due to the ethnic conflict in the country. Another reason for urethral disease to be common in Sri Lanka is the high incidence of balanitis xerotica obliterans (3). Since the diagnostic (eg. urodynamics) and therapeutic options ( eg. artificail urinary sphincters, bladder reconstruction surgery and urethroplasty) available in Sri Lanka are limited, CIC can be used in the suuccessful management of these patients. Several years ago a major drawback in popularising CIC in Sri Lanka was the non-availability of low friction hydrophilic catheters due to its high cost. Hence we started a CIC programme using ordinary Foley catheters (silicone-coated latex). Since silicone-coated latex catheters were kept for one month when used as indwelling catheters, we recommended the patients to use the same catheter for one month to keep the cost to a minimum.The patients were advised to rinse the catheter with soap and water before and after use and to store in a clean plastic box or bag. Initially the patients were advised to use 2% lignocaine jelly to lubricate the catheter but after few days most of them managed without it. An audit of the CIC programme after one year revealed that twenty-eight patients with an age range of 2 to 70 years were successfully practising CIC (4). Only three patients had complications; orchitis, cystitis and asymptomatic bacteriuria. After the initial success several other units in the country have adopted this low-cost technique. In our unit alone more than 100 patients have been trained to perform CIC during the last four years enabling them to be in better control of their bladders and micturition. These are just two examples of many improvisations that surgeons in developing countries use to provide effective surgical care to their patients. Large economic advantages of these techniques outweigh the minimal clinical disadvantages. It is important to realise the advantages of developing better surgical skills and cheaper innovations rather than depending on very expensive technological advances to improve patient care. References. 1. Hill AG. Training in the west to work in the developing world. Annals of the Royal College of Surgeons of England (Suppl) 2004; 86 : 56-58. 2. Kirollos MM, Campbell N. Factors influencing blood loss in transurethral resection of the prostate(TURP): auditing TURP. Brotish Journal of Urology 1997 ; 80 : 111-115. 3. Abeygunasekera AM, Jayasingha R, Duminda KMT. An observational study of Balanitis Xerotica Obliterans. Sri Lanka Journal Of Urology 2004; 4 : 18- 20. 4. Abeygunasekera AM. Clean intermittent catheterisation: can we do better? Sri Lanka Journal of Urology 2000; ! ; 15-17. Competing interests: None declared
“Take health into our own hands” – Community-based health insurance in Burkina Faso 6 May 2004
Manuela De Allegri, PhD student Department of Tropical Hygiene and Public Health, Heidelberg University, 69120 Heidelberg, Germany, Bocar Kouyaté, Rainer Sauerborn (see text for affiliations) Send response to journal: Re: “Take health into our own hands” – Community-based health insurance in Burkina Faso	Assurance Maladie ŕ Base Communautaire. In the local language, Djula, the pronunciation of the acronym derived from this French expression translates into meaning, “We can do it”. Starting on February 3rd, 2004, communities in the Nouna Health District, Province of Kossi, Northwestern Burkina Faso, have decided, as stated on the posters that cover the town and the surrounding villages, to “take health into their own hands”. Having identified that cost of health care services represents the main obstacle to their access (1), local communities, in collaboration with their Health District and our research institutions, had long been thinking of launching a community-based health insurance scheme. By pooling risks and resources across a community, such schemes have the potential to facilitate access to health care services (2;3), and limit catastrophic spending due to illness (4). However, given the evidence that failures in the design and the management of the schemes can seriously hinder their viability (3), extensive research was first conducted in the area to determine how insurance principles could be matched with local cultural and socio-economic expectations in the development of a viable scheme. Over the course of the past few years, research has been conducted to estimate cost of health care interventions, community preferences for a benefit package, and people’s willingness to pay for such package (5). Discussing the result of the research with the local population has led to the development of an evidence-based health insurance scheme which, while resting on sound insurance theory, is fully owned and managed by the local community. To avoid adverse selection, the household has been defined as the enrollment unit. To limit moral hazard, effective gate-keeping has been set in place requiring that enrolled members always seek care at first-line facilities and only in case of need, are referred to the district hospital. To limit possible over-provision of services, the Health District has accepted that providers are paid on a capitation basis. The community has not only actively participated in making each of the above decisions with regard to the scheme design, but it has also, and most importantly so, already elected its representatives handing them the authority to manage the scheme. With technical assistance from our institutions, the elected representatives are currently carrying to an end the first enrollment campaign. They trust not only in their ability to improve health status in the area through better access to services, but they also hope to serve as an example for the neighboring communities in the province and elsewhere in the country. Manuela De Allegri (1) Bocar Kouyaté (2) Rainer Sauerborn (1) (1) Department of Tropical Hygiene and Public Health - University of Heidelberg, Heidelberg, Germany (2) Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso References 1. Sauerborn R, Ibrango I, Nougtara A, Borchert M, Hien M, Benzler J et al. The economic costs of illness for rural households in Burkina Faso. Trop.Med.Parasitol. 1995;46:54-60. 2. Criel B, Kegels G. A health insurance scheme for hospital care in Bwamanda District, Zaire: lessons and questions after 10 years of functioning. Trop.Med.Int. Health 1997;2:654-72. 3. Atim C. The Contribution of Mutual Health Organizations to Financing, Delivery, and Access to Health Care: Synthesis of Research in Nine West and Central African Countries. Partnerships for Health Reform Project, Abt Associates Inc., Bethesda, USA, 1998. 4. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet 2003;362:111-7. 5. Dong H, Mugisha F, Gbangou A, Kouyaté B, Sauerborn R. The feasibility of community-based health insurance in Burkina Faso. Health Policy (in press). Competing interests: None declared
Learning from developing countries. 7 May 2004
Prakash C. Das, Retired Redgerstraat 10, 9791 BH Ten Boer, The Netherlands Send response to journal: Re: Learning from developing countries.	Lessons from Developing Countries. Editor, In the Heart of Darkness Joseph Conrad suggests it is impossible to share one’s life experience but maybe one should attempt to convey the feelings. I attempt to share my experience in Malawi. Independent in 1964 this relatively small country in Africa carrying an external debt of US$ 2.3 billion, is one of the poorest country in the world. Majority of 11 million Malawians live in rural area- 90% of them in abject poverty. But people are friendly; the scenes are beautiful with shimmering lakes and peaceful mountains; the tourist brochure declares it to be the “warm heart of Africa” There is only one medical school, - the college of medicine ( COM ) was started in 1986 and situated in Blantyre. As a haematologist I joined the COM in 1999, affiliated to the local central hospital with 1200 beds. Soon after I was asked to see a patient who remained anaemic despite blood transfusion, in gynaecology depertment. The barrack was full with patients and crowded by attending relatives. The patient was a young pregnant woman with fever, confusion and oral thrush. A quick examination revealed apparent pinprick like marks on her abdomen, especially concentrated on the site of the uterus. An enquiring look at the resident doctor, who was also acting as a translator, established that the patient had been seen by a traditional healer before attending the hospital. With the clinical history and with the few laboratory tests that could be done locally a tentative diagnosis of haemolytic uremic syndrome related to AIDS was made. Realising that this case may be the first to be observed in the country (1), a seminar was organised where the most modern knowledge about the disease was presented, including the roles and interactions of high molecular vW factor, endotoxins, and vascular endothelium, - all high powered stuff for clinical teaching. After the meeting the resident doctor went back to the ward to convey the probable diagnosis and treatment possibilities. To follow up how the treatment was proceeding, next day I visited the ward to find an empty bed; the sister informed me that the attending family members had signed the discharge form and taken the patient home. I felt inadequate and was sad ; and it struck me suddenly that such diagnosis implied an immediate and considerable burden of costs. Furthermore the essential cause of her ailments, while scientifically based, sounded mumbo- jumbo or witchcraft. The village healer may have provided similar sounding explanations, and his treatment cheaper and near their home. The signs were there but I missed it completely despite my broad experience – youth in India, medical study in UK and subsequent practice in Europe. I was beholden to the current trend of scientific based medicine, and was looking for the recognition of priority rather than acknowledging the face of humanity; my failure of spirit and empathy, and my cognizance of this failure is one of the lessons in the area of darkness. Had I been more exposed to the local traditions and culture I would have treaded the platform more gently, perhaps allowing the patient some suitable affordable treatment. We need to pare away personal prejudice and preconception to reach a comprehensive understanding of the person in need, and to care for them.(2). There is also another side brought home to me. A child had sudden seizures and brought into the paediatric ward. My paediatric collegue who had lived longer in Malawi and could speak the local language treated the patient, but the child died due to meningitis.(3) The mother was quite sure that some witch spell had been cast upon the child by the next door neighbour. The pediatrition explained to the grieving mother that the real cause of death was bacteria, -invisible enemies present in the air and surroundings; her sympathetic narration soothed the mother’s anger and brought the two neighbours close again with friendship. The paeditrcian through her good grasp of the local beliefs and traditions was able to bring understanding in the face of grief and distress with the help of scientific facts. Of the two interventions, one seemed to be “successful” and the other apparently failed. What can we learn? In developing countries the concept of norm may not follow the western examples. Health is a dynamic process dependent on local culture and traditions, doctor’s views and patient’s expectations. The lesson for me must be to listen with understanding to the patients. This is especially so in the western rich countries now facing the effect of demographic change resulting in an abundance of elderly people; we may not always be able to cure their chronic ailments and disabilities but we can always listen to them and appreciate their right to explanations. This gives reassurance and satisfaction to the patient and also to the community. One may hope that this will lead to a reduction of cost in health care. P. C. Das Redgerstraat 10, 9791 BH Ten Boer, Netherlands. Acknowledgment: Thanks to Professor E. Molyneux for explaining local traditions. References: 1. Tadessi Y. E. , Das. P. C. A febrile confused young woman. Malawi Medical Journal 2001; 13: 51. 2. Vaux. T. The Selfish Altruist. Earthscan Publications Ltd, London, 2001: 5. 3. Molyneux E M, Walsh A L, Forsyth H, Tembo M et al. Causes and outcome of bacterial meningitis in children. Malawian Medical Journal 2003; 15: 43-46. Competing interests: ex associate professor haematology, COM, Malawi.
Controlling the cholera epidemic in Peru: The community’s Oral Rehydration Units 8 May 2004
Walter H. Curioso, School of Public Health and Community Medicine University of Washington, Box 357660, Seattle, WA 98195, USA., J. Jaime Miranda, Ann Marie Kimball Send response to journal: Re: Controlling the cholera epidemic in Peru: The community’s Oral Rehydration Units	Controlling the cholera epidemic in Peru: The community’s Oral Rehydration Units To the editor: Cholera is a disease closely linked to social, economical and political change, and today’s world reflects it. In early 2004, WHO reported cholera outbreaks in Chad, Mozambique and Zambia. In 2003, several developing countries, were on the list (1). Cholera became a worldwide disease in 1826, and it remains as such. Cholera occurred unexpectedly in the American continent in 1991 (2), following a century of absence of this disease in that side of the world. Peru was the first country to report cases of cholera and also the country most severely affected by the epidemic, not only in terms of numbers: almost 300 000 cases during the first year of the epidemic and approximately 45 000 cases per week during the first few weeks, but also in terms of the significant impact that the epidemic had on its impoverished economy (3). The cholera outbreak in Peru in 1991 cost the country a minimum of US$ 770 millions due to food trade embargoes and adverse effects on tourism (4). The case fatality rate in Peru was recorded as only 0.7%, the lowest rate in South America during the 1991-1994 period and one of the lowest ever reported (5, 6). On the contrary, the aftermath of the Rwanda crisis in 1994, outbreaks of cholera caused at least 48 000 cases and 23 800 deaths within one month in the refugee camps in Goma, Democratic Republic of the Congo (4). The conditions in those settings were different, but these massive effects warrant a degree of international exchange of experiences. Public consciousness and prompt rehydration treatment, in a system where a response was already in place for diarrhoeal diseases, were the key factors behind the successful medical response to the epidemic in Peru. The general population was alerted promptly, and information on preventive measures was widely disseminated through the media. The Peruvian Ministry of Health recommended 1) the exclusive use of boiled water for drinking, 2) careful washing of fruits and vegetables using clean water, and 3) washing of hands. Even though the country -and the continent- was taken by surprise, the rapid and effective response was facilitated by the fact that extensive Oral Rehydration Units (ORU) had been put in place years before, as a response to the problem caused by childhood diarrhoeal diseases. Since 1980, the ORUs were established in periurban health centers. Training campaigns were carried out among mothers of the voluntary popular organisations (Mother’s Club, Glasses of Milk). Later, ORUs bases were extended to the pediatrics department of hospitals (5). When cholera appeared, it was widely held that Peru would have great difficulties in stopping the epidemic. But for the Peruvian Ministry of Health the objective was that the mortality rate should be zero, to be achieved by an intensive and a persistent cholera national programme. Previous national experience allowed health staff and communities to institute the massive use of rehydration therapies on all populations in a large scale. In conclusion, the cholera epidemic of 1991 has taught us how to employ the clinical and epidemiological information and make the most of a system already in place, decreasing the mortality to the lowest levels with simple and easy schemes to follow. A lesson to be shared, and hopefully to decrease the list of countries affected by cholera outbreaks these days. Walter H. Curioso, MD School of Public Health and Community Medicine, University of Washington, Box 357660, Seattle, WA 98195, USA. wcurioso@u.washington.edu J. Jaime Miranda, MD International Health and Medical Education Centre, University College London, London N19 5LW, UK. j.miranda@ucl.ac.uk Ann Marie Kimball, MD, MPH, FACPM Professor, Epidemiology and Health Services, School of Public Health and Community Medicine, University of Washington. akimball@u.washington.edu References (1) WHO. Cholera. Available at: http://www.who.int/csr/don/archive/disease/cholera/en/ (accessed 2 May 2004). (2) Seas C, Miranda J, Gil AI, Leon-Barua R, Patz J, Huq A, Colwell RR, Sack RB. New insights on the emergence of cholera in Latin America during 1991: the Peruvian experience. Am J Trop Med Hyg 2000;62(4):513-7. (3) Panisset U. International Health Statecraft: Foreign Policy and Public Health in Peru’s Cholera Epidemic. Lanham: University Press of America, 2000. (4) WHO. Impact of cholera. Available at: http://www.who.int/csr/disease/cholera/impactofcholera/en/ (accessed 2 May 2004). (5) Gotuzzo E, Cieza J, Estremadoyro L, Seas C. Cholera. Lessons from the epidemic in Peru. Infect Dis Clin North Am 1994;8(1):183-205. (6) Update: Vibrio cholerae O1--Western Hemisphere, 1991-1994, and V. cholerae O139--Asia, 1994. MMWR Morb Mortal Wkly Rep 1995;44(11):215-9. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00036609.htm (accessed 2 May 2004). Competing interests: None declared
Health districts in Western Europe: the Belgian local health systems project 13 May 2004
Jean-Pierre Unger, Senior Lecturer Department of Public Health, Institute of Tropical Medicine, 2000 Antwerp, Belgium, Bart Criel, Jean Van der Vennet, Sylvie Dugas, Patricia Ghilbert, Pierre De Paepe, Michel Roland Send response to journal: Re: Health districts in Western Europe: the Belgian local health systems project	Sir, In 1987, WHO started promoting districts as baseline administrative units for health systems (1). Since then, many developing countries have adopted this policy* , theoretically to improve management through decentralisation, to make top-down meet bottom-up planning, and to integrate general practice, hospital care and disease control. The (too rare) successful experiences suggest that effective districts require: - largely overlapping administrative and operational pyramids to enable management to address health care problems; - an executive team able and willing to coach health professionals, enjoying some degree of autonomy and authority over the health services(2); - two interconnected tiers (first line and hospital facilities). Belgium is characterised by private ‘not-for-profit’ hospitals, a professional bureaucracy (3) and self-employed first line doctors. These last two increasingly characterise European health systems. However, there is no middle line health care management structure. The local health systems (LHS) project (4) started in 1994 to tackle this challenge and implement the rationale of developing countries’ districts in Belgian pilot areas. With the technical assistance of an academic unit, voluntary networks of health professionals used their influence to improve quality of care, coordination between tiers, hospital management and GP associations. Three out of seven areas still operate in Brussels, Antwerp and Malmédy. Methods aimed at bridging the gap between health care delivery and management, through education-oriented supervision, ‘inter-vision’ (peer review of difficult case management), action research, medical audits and managerial interventions. Results encompassed negotiations between tiers/providers, rationalisation of clinical decision making, in-service training for GPs, patient sensitisation, improvement of management control systems (e.g., GP access to computerised hospital files), reorganisation of hospital services and procedures (laboratory, radiology,…), reduction of hospitalisations. As participants discovered, relationships and coordination between actors improved significantly. Participation from committed doctors, nurses and professional organisation representatives proved pivotal for success. Other positive factors included selection of areas with favourable conditions (e.g., networks of friends); external technical assistance; and modest ad hoc funding (this 10-year action research project received financial support from government for four years). Such a stewardship strategy could prove unique in integrating health systems in professional bureaucracies settings, alongside financial incentives (5). As a feedback for developing countries where middle line administration is not always staffed by the right people, networks of committed health professionals could externally influence the management of health facilities and resources and take over some district functions. * Some European countries also adopted the terminology, but promoted other rationales such as preventive medicine or very large entities designed to manage specific resources 1. Report on the Interregional Meeting on Strengthening District Health Systems Based on Primary Health Care. Harare, Zimbabwe, 3 to 7 August 1987. WHO, Geneva, 1987. 2. M.Segall. District health systems in a neo-liberal world: a review of five key policy areas. Int J Health Planning and Management 2003; 18: S5-S26 3. J.-P. Unger, J. Macq, F. Bredo, & M.Boelaert. Through Mintzberg's glasses: a fresh look at the organisation of ministries of health. Bull WHO 2000; 78 (8): 1005-1014 4.J.-P.Unger, B.Criel, S.Dugas, J.Van der vennet, M.Roland. The local health systems (LHS) project in Belgium. Presentation at the 11th annual EUPHA meeting. Globalisation and Health in Europe: Harmonising Public Health Practices. 20-22 November 2003, Rome, Italy. Abstract, European Journal of Public Health 2003; 13 (Suppl.): 26 5. E.-L.Hultberg, K Lonnroth, P Allebeck. Using pooled budgets to integrate welfare systems: a comparison of collaboration between health services, social services and social insurance in England and Sweden. Presentation at the 11th annual EUPHA meeting. Globalisation and Health in Europe: Harmonising Public Health Practices. 20-22 November 2003, Rome, Italy. Abstract, European Journal of Public Health 2003; 13 (Suppl.): 25- 26 Competing interests: None declared
Learning from the developing world: sources of information 20 May 2004
James N Newell, Senior Lecturer in Epidemiology & Public Health Nuffield Institute for Health, University of Leeds, 71-75 Clarendon Road, Leeds, LS2 9PL, UK, Andrew S Furber Send response to journal: Re: Learning from the developing world: sources of information	Many general medical journals claim an international focus: in the UK, the BMJ states that “it seeks to be at the forefront of the international debate on health”(ref 1), while The Lancet has claimed to be “a leading voice in coverage of global public health” (ref 2). We decided to test the journals’ claims of global relevance, and to assess the opportunities for UK readers of these journals to learn from research from the developing world. The objectives of this study were (1) to assess the claims of the BMJ and the Lancet that they have international relevance, and (2) to assess to what extent there is an opportunity for health professionals working in the UK health system to learn from experience from developing countries from these two journals. Research articles from the BMJ (“papers” and “primary care” sections) and The Lancet (“articles”) from 1 March 2003 to 28 February 2004 were abstracted, the start date of the latter being chosen to reflect the Lancet’s call for medicine’s global responsibilities to be strengthened (ref 2). Each article was assessed as (1) relevant or not relevant to developing countries, and (2) providing or not providing an opportunity for health professionals working in the UK health system to learn from experience from developing countries. Each article was independently assessed by the two authors. We found that 75 of 292 (25%) and 50 of 163 (31%) papers in the BMJ and The Lancet respectively were relevant to developing countries, largely in the fields of TB, HIV and SARS. Only 14 (5%) and 19 (12%) respectively provided an opportunity for health professionals working in the UK health system to learn from experience from developing countries. Our results indicate that despite their claims, both the BMJ and The Lancet continue to focus on wealthy countries to the exclusion of research relevant to developing countries. Furthermore, the opportunity for the UK NHS to learn from developing countries is very restricted. We would like to see journals that claim to have global relevance to make concerted efforts to encourage publication of articles from developing countries. This could be achieved by providing training in writing for international journals, soliciting submissions, accepting articles in languages other than English, assisting in editing suitable articles, and encouraging collaboration between experienced and less experienced researchers, whatever their origin. References 1. http://bmj.bmjjournals.com/aboutsite/aboutbmj.shtml (accessed 16/4/04) 2. Horton R. Medical journals: evidence of bias against the diseases of poverty. Lancet 2003; 361: 712-13. Competing interests: None declared Competing interests: None declared
Learning from developing countries - Neighbourhood Network in Palliative Care – An innovative experiment in Long Term care (LTC) and Palliative Care (PC): 1 September 2004
Suresh Kumar, Director Institute of Palliative Medicine, Medical College, Calicut, Kerala 673008 India Send response to journal: Re: Learning from developing countries - Neighbourhood Network in Palliative Care – An innovative experiment in Long Term care (LTC) and Palliative Care (PC):	Neighbourhood Network in Palliative Care (NNPC) is an attempt by a group of doctors and social activists in the South Indian state of Kerala to develop a sustainable ‘community lead’ service capable of offering comprehensive Long Term Care (LTC) and Palliative Care (PC) to the needy in the developing world. In this program, volunteers from the local community are trained to identify problems of the chronically ill in their area and to intervene effectively, with active support from a network of trained professionals. Essentially, NNPC aims at empowering local communities to look after the chronically ill and dying patients in the community. The philosophy: People with incurable diseases have problems different from those being treated by health care institutions for acute illness. These chronically ill people are in need of regular care for the rest of their life. Palliative Care aims at ‘total care’. But putting the concept of ‘total care’ with continuous support in physical, psychosocial and spiritual realms into practice is very difficult through ‘institutionalized’ care. What is being offered usually by palliative care centers is a ‘patchy’ service through which the patient and family has access for a few hours once in a while to the facilities available for the control of physical symptoms and /or emotional support. Patients with incurable diseases have medical and nursing problems. But these occupy only a part of a complex situation, which can not be addressed by a doctor / nurse / palliative care center. Issues associated with chronic / incurable illness are basically social problems with a medical component. This is all the more so in the developing world. Most of the problems of the chronically / incurably ill need to be handled by the society. For this to happen, the community should be in charge of the program rather than a few volunteers among them taking predetermined slots in the palliative care units / home care programs run by health care professionals. The ‘modus operandi’: Under the program, people who can spare atleast two hours per week to care for the sick in their area are enrolled to undergo a structured training program (15 hours of interactive theory sessions + four clinical days under supervision). On successful completion of the training (which includes an evaluation at the end) the volunteers are encouraged to form groups of 10 –15 community volunteers and to identify the problems of the chronically ill people in their area and to organize appropriate interventions. These NNPC groups are supported by trained doctors and nurses. NNPC groups usually work closely with the existing palliative care facilities in their area or build such facilities on their own. Volunteers from these groups make regular home visits to follow up the patients seen by the palliative care team, identify and address a variety of non medical issues including financial problems, identify patients in need of care, organize programs to create awareness in the community and to raise funds for palliative care activities. Community volunteers act as the link between the patient in the community and the health care institution. Results so far: NNPC programs, have shown exceptionally good success rate in all the places where they have been launched. In a socio economically backward district in Kerala (Malappuram with a population of four million) where the program was first ‘ground tested’, the coverage of LTC and PC rose to 70% in two years time. The other three districts in Kerala (Wynad, Kozhikode, Trichur) where the program has been launched over the last two years, are also showing the same steep upward trend in coverage and quality of care. More than 50% of coverage for all chronically ill patients within two years of initiation of the project seems to be the rule. Areas where NNPC programs are in operation show an LTC and PC coverage much higher than the rest of Kerala (in fact much higher than anywhere in the developing world where the 'estimated' coverage is between 0 – less than 5%). NNPC projects are now being taken up in two more districts in Kerala and a couple of villages in Assam. The project has also managed to bring many groups and social initiatives (student groups in the campuses, literacy movement, cultural organizations, women’s groups, teachers’ organizations etc..) on a common platform working for the chronically ill. NNPC now has about 30 organizations in the region participating in it. It actually has achieved the status of a popular movement in health in the area. This was evident in the recent observation of a “Palliative Care Day” in Kerala by the community groups. The ‘first generation’ volunteers are now acting as trainers to train more laypersons. ‘Train the trainer’ programs emphasising on psychosocial support for the patient has been exceptionally good successes as evidenced by the skills and confidence of the volunteer trainers who go through the program. All the district programs and some of the village level programs now have their own ‘training machinery’. Costs / Funding: External intervention into a community can be tricky; many well-meaning interventions in the past have inadvertently made local communities less self-sufficient. When taking up the facilitation process, the initiating group was well aware of this possible trap and hence the local community is involved in the process in all the stages from planning to monitoring. The strategy of NNPC is to work with the people rather than for the people. It was this philosophy of ‘ownership to local people’, which has resulted in the phenomenal success of the program. It has been shown that when the neighbourhood groups are in charge of the programs, expansion and achievement of financial sustainability is quick. All the neighbourhood groups under the program have managed to raise the money needed for the delivery of the care locally through small contributions and support from the local government. This ‘economic independence’ of the program helps the local communities to be in full charge of the initiatives. It was seen that many of these groups later move on to additional areas of health care like care of the patients with chronic psychiatric disorders, interventions in areas like infectious diseases like tuberculosis etc.. In situations where external funding is needed, NNPC initiatives need it only for initiation. The programs become self sufficient in 2-3 years through generation of local funding. Altogether, 80% of the funds for the NNPC programs are mobilised locally through donations within the community and support from the local government. The advocacy role that the groups play has resulted in generating good support from the government in all the places where the program is active. Funds raised from the local community are mainly through small donations (eg; a rupee - about two cents - a day from lower middle class and poor families and shopkeepers, donations from students in various campuses, regular donations from manual labourers etc..) The external agencies, which supported the NNPC program over the last three years with the rest of funding (appx 20% of total costs) include Help the Hospices (UK) WB Davis Charitable Trust (UK) and Cancer Relief India (UK) The total expenditure for NNPC programs in 2003 was approximately 12 million rupees (US$ 285,000) out of which US$ 220,000 was small donations from the massive support base in the community. Relevance of the project: NNPC serves as a realistic option for most of the developing world to develop the much needed sustainable services for the chronically ill and dying patients. The model assumes extra significance because of the growing number of elderly and people affected with incurable disease like AIDS and advanced cancer having no access to care in the face of rapidly escalating health care costs. In addition to the large number of patients directly benefited by the program, the NNPC program also have the impact of building confidence and trust among the individuals in the communities. The community participation in health care activities is an exceptionally good way of growth and development of individuals. The spirit of volunteerism with options for working in a team to identify and improve local issues helps people to achieve immense amount of self-growth. This has been proved by the 5000 odd community volunteers who include people all socio economic backgrounds from different walks of life like students, pensioners, house wives, teachers, professional, manual labourers etc. In addition, hundreds of people have been ‘waitlisted’ for training. Another major achievement of NNPC programs is that they have managed to bring together a variety of different social initiatives on a plat form of social justice to work together for the chronically ill and dying patients in the community. The program, in all the places where it runs, has achieved the dimension of a popular movement. Since all these were done in a structured way, there is good scope for replication for the NNPC model – Which means that there is a possible alternative option for Palliative Care and Long Term Care for the so- called poor communities in the Developing World. Competing interests: None declared
Learning from less developed countries: From rural hygiene to strengthening peace 21 September 2004
Stella Fatovic-Ferencic, MD PhD Croatian Academy of Sciences and Arts, Zagreb, Croatia, Željko Dugac MD PhD Send response to journal: Re: Learning from less developed countries: From rural hygiene to strengthening peace	Knowledge does not work in one direction, just for being applied to a target. It always offers a return, at times even with greater effect. The forum on learning from less developing countries stimulated us in describing the model of improving health care in the Kingdom of Serbs, Croats, and Slovenes conducted after World War I, when the Rockefeller Foundation and the League of Nations started its projects on internationalisation of public health, in this part of the world. Our opinion was that such a historical model could be potentially helpful in evaluating and judging lessons in both directions. A new country, the Kingdom of Serbs, Croats, and Slovenes (SCS) was established after the World War I on the territory of central and southeast Europe. It was a territory inhabited by 10 million people approximately, with the majority of population concentrated in rural areas. Outbreaks of epidemics, infectious diseases, and a high mortality rate of children, as well as poor sanitary and hygiene standards were commonly met. Considering the mass poverty and the wide circulation of epidemics, the urge for organised health care on a broader basis became apparent. This was eventually initiated by the two key institutions the League of Nation Health Organisation and the Rockefeller Foundation. It was actually the time period in which the Rockefeller Foundation established various public health institutions throughout Europe. The First School of Public Health founded at the Johns Hopkins University in Baltimore in 1918 became a research centre for Rockefeller experts and numerous scholarship holders from different countries, and it soon became the model according to which other schools were later built throughout Europe, in London, Warsaw, Budapest, Zagreb etc. (1,2). The Rockefeller Foundation program for the Kingdom of SCS was primarily based upon application of the public health education as well as organization and establishment of the public health infrastructure. Sanitary engineering associated with popular health education, was advocated in order to improve poor hygienic conditions in the local community, as well as to present scientific and medical achievements in a practical way. Close cooperation with the local government and local experts was paramount in achieving those goals. The basic form of aid which the organisation gave to the Kingdom of Serbs, Croats, and Slovenes included cooperation with the national health care administration to help establish hygienic institutes, hygienic and nursing schools and a new form of health care organisation respectively; awarding scholarships and help for research work. The realisation of Foundation’s programs required substantial health reforms on this territory as well as proper public health managers to carry them through. The Foundation supported the national health care administration financially by building the School of Public Health in Zagreb, (opened on October 3rd 1927), while the cooperation was carried out mainly by Andrija Štampar (1888-1958). To ensure the support for the initiated reforms Štampar was given $ 290,000 for the construction and equipment of the School of Public Health in Zagreb, and for the equipment of the Epidemiological Institute in Belgrade later called the Central Hygienic Institute (3). The School of Public Health was certainly the most active and the most prominent public-health institution in the Kingdom of SCS, although also numerous other public health institutions were founded on this area during subsequent years. In the period between 1920 and 1925 for example 250 institutions such as epidemiological institutes, bacteriology and parasite laboratories; health clinics; outpatient facilities for venereal diseases, tuberculosis, trachoma treatment centre; mother and child protection offices; school polyclinics etc. were established inside the borders of the state. Parallel to the institution network professional personnel training programs were established. Apart from university education, medical students were able to familiarise themselves with problems of social medicine during obligatory practice in the rural area (4,5). Rockefeller documents reveal that the Department of Hygiene of the University of Zagreb received $25,000 from the Foundation for undergraduate courses on hygiene and field training for the period 1927-1930 (6). Physicians who went to work for the newly established institutions were confronted with all forms of preventive and social-medical work in the communities. They received additional training in the field of public health care through scholarships and further professional training in Europe and USA (7). The intensive public health work that was carried out in the Kingdom of Serbs, Croats, and Slovenes was evaluated as very successful by the international experts and as Carl Prausnitz wrote in his book ”The Teaching of Preventive Medicine in Europe” Perhaps of all central and south-eastern countries of Europe, Yugoslavia is most interesting instance of whole- hearted and successful preventive medicine work, both in its teaching and practical aspects (8) Two main contributions resulted from the early work of the School and international experts: one with respect to infectious diseases control and the other to life expectancy gains. The later bears a strong link to the effective training of a substantial number of public health professionals. Regrettably the political situation contributed to Štampar’s dismissal from the Ministry of Public Health in 1931, and the most progressive era in the public health care field was replaced by the decline in public-health care in this area. On the other hand Andrija Štampar, was supported and stimulated to use his experience and transmit it worldwide as an expert of the Rockefeller Foundation and the Health Section of the League of Nations. Furthermore he was entrusted to conduct challenging tasks in China where, at the beginning alone and later with his collaborator Berislav Borčić (1891-1977), the first head of the School of Public Health in Zagreb, he coordinated public health programs (rural sanitation, health education, epidemics control, vaccination ) similar to those used and approved in the Kingdom of SCS. Both Štampar and Borčić stayed in China for several years and participated actively in developing public health programs. Berislav Borčić went to China on three occasions between 1930-1938 as the member of the League of Nations where he worked as Medical Adviser to the Chinese Government. In the period 1946-1948 he was the Chief Delegate of the World Health Organization and the Head of UN Mission sent to China to help this country after the war (9). According to the reports of both experts shifts in public health education and in prevention of diseases in China were unquestionable, but it also became clear that use of a standardised intervention across cultures may not always be appropriate in all aspects. The necessity of development of interventions that are more culturally orientated appeared to be mandatory (10). The flow of activities initiated in the USA, transmitted to Europe and applied successfully to the Kingdom of SCS, then partly to China and other undeveloped parts of the world, completed its circle in America again where Štampar gave a series of lectures when invited as a visiting professor by the Harvard Medical School and Rockefeller Foundation. Already then he was aware of the fact that public health is too important to be left just to public health professionals. Many of the decisive circumstances of health care are influenced by public policies across a range of sectors including finance, general education, social welfare, retirement benefits, and agriculture. He tried to promote the idea that policy makers should be engaged more effectively in considering the implications of their decisions on the health of the populations they serve. It is important to note, however, that some ideas and messages which he intended to convey, such as social and health care insurance are a necessity. These views did not meet American interests, and were not fitting well into the vision of the American health administration as well as American Physician´s Association. (11) After the World War II the specialized agency which will take care about the world health was planned to be established. In 1945 A. Štampar became president of the Social and Economical Council of the UN, and one year later, the president of the Interim Commission of the WHO, which took all competences of the WHO in the period before its legality in 1948. Through this time Štampar played an important role in the process of preparing the constitution of the WHO, which was finally established on 7 April 1948. On the other hand the role and legacy of Berislav Borčić was also appreciated. He served for UNICEF in Paris and New York as WHO representative during 1948-1955 and in 1955 became Deputy Director General of UNICEF for two years (9, 12). The model presented here was selected not only for its historical value but to draw attention to long lasting and profound benefits of exchanging health lessons globally. School of public health and its leading personalities certainly paved the way for many physicians and engineers that were educated under the influence of the modern public health spirit in the subsequent periods, who received various fellowships for education abroad, mostly from the Rockefeller Foundation. They continued the work in the field of public health in the following decades and introduced an original approach to the public health problem, popular health education, rural medicine and sanitary engineering in different countries. They became new partners for the Foundation and for the international medical community in the inter-war period as well as after the Second World War. All such educated experts were oriented toward trends which were modern in the world at that time and which aspired to the internationalisation of public health, trying to overcome national, ethnic and religious differences. In a multinational country like the Kingdom Serbs, Croats and Slovenes whose parts differed culturally and economically, the internationalisation process of public health was regarded as a model by which the diversity that existed in the newly founded Kingdom could be brought together and be integrated into a new coherent national public health program. Those projects demonstrated clearly that mutual collaboration brought enormous benefit not only to the developing Kingdom of SCS were it was applied but provided improvement of health to other developing countries as well as it offered evidence of relevance and value to the developed ones. It certainly confirmed further that the future of public health lies in close international collaboration. Enormous global changes occurred since, many of which have tremendous implications for public health. Morbidity has changed extensively, new diseases occurred, increasing problems of multi drug resistance is manifesting itself, wars are waged, great migrations of populations emerged. For quite some years now, the Kingdom of SCS does not exist any more, and several new and independent states were formed in its place. Despite of the profound political and social changes, public health institutions established after World War I still exist and are exceedingly active. They continue to represent the core of national public health programs, persisting on the main doctrines since their establishment. In Croatia for example the School of Public Health which bears the name of Andrija Štampar now is engaged in activities with the institutions of similar interest, with different countries and collaborates with WHO and other international institutions. It participates in international projects, postgraduate courses and is the leading institution in public health education for the countries of South-eastern Europe. It contributes profoundly in developing the strategies in the spirit of public health, in strengthening peace, and identifying models of public health practice, based upon experience in past wars and conflicts (13) - certainly bitter but paramount lessons to be conveyed to the world, particularly in an era of terrorism in which we live at present. Stella Fatovic-Ferencic MD PhD Department for the History of Medical Sciences, Institute for the History and Philosophy of Science, Croatian Academy of Sciences and Arts, Gundulićeva 24, 10 000 Zagreb Croatia E-mail stella@hazu.hr Željko Dugac MD PhD Department for the History of Medical Sciences, Institute for the History and Philosophy of Science, Croatian Academy of Sciences and Arts References: 1. Löwy I, Zylberman P. Medicine as a Social Instrument: Rockefeller Foundation, 1913-45. Studies in History and Philosophy of Biological and Biomedical Sciences 2000; 31: 365-79. 2. Weindling P. Philanthropy and World Health: The Rockefeller Foundation and the League of Nations Health Organisation. Minerva 1997; 35: 269-81. 3. Help of the Rockefeller Foundation for our Ministry of Healt (in Croatian). Glasnik ministarstva narodnog zdravlja 1924; 5: 785-6. 4. Štampar A. Five years of working on hygiene (in Croatian). Glanik Ministarstva narodnog zdravlja 1925; 6: 289-91. 5. Dugac Ž. Foundations of the Health Promotion in Croatia (PhD thesis) (in Croatian). Zagreb: University of Zagreb; 2003, pp. 25-40. 6. Minutes of the executive committee of the International Health Board of the Rockefeller Foundation. June 23 1926. RG.7.10.C.1.1.B.4.F.30. Rockefeller Archive Center. New York. 7. List of foreign fellowships granted by the International Heath division of the Rockefeller Foundation to personnel employed in the public health in the Kingdom of SCS 1924-1927. RG.7.10.C.1.1.F.43. Rockefeller Archive Centre, New York. 8. Prausnitz C. The Teaching of Preventive Medicine in Europe. London: Oxford University Press; 1933, p. 121. 9. Belicza B, Rastija M. Dr. Berislav Borčić (1891-1977), expert of the League of Nations and the World Health Organization (in Croatian). Saopćenja 1984; 27: 129-44. 10. Štampar A. Health and social conditions in China (in Croatian). Liječnički vjesnik 1937; 59: 323-79. 11. Štampar A. New spirit in America (in Croatian). Liječnički vjesnik 1939; 61: 80-7. 12. Grmek M. D. The life of Andrija Štampar and his achievements in improving public health (in Croatian). In: Grmek M. D, ed. Selected Papers of Andrija Štampar. Zagreb: Škola narodnog zdravlja «Andrija Štampar»; 1966, pp. 45-7. 13. Lang S. Kovačić L.Šogorić S.Brborović O Challenge of Goodnes III: Public Health Facing War. Croat Med J. 2002; 43: 156-165. Competing interests: None declared
Learning for the betterment 22 September 2004
Kaushal R Pandey, MBBS fourth year student TUTH, IOM Send response to journal: Re: Learning for the betterment	The Editor, It is a high time that BMJ has taken a decision to publish a theme issue on Learning from developing nations when those countries are leaving their good attributes in the quest of becoming like the developed nations. Joint family culture, Yoga and meditation, Emphasis on clinical skills rather than sophisticated investigations are a few things; I believe the developed nations can learn from developing nations. Rather than giving more emphasis on providing social security, if joint family culture be applied, it can be a great individual security factor and prevent many sorts of psychological problems to a great extent. Even more yoga and meditation can be miraculous approach to preventing obesity and depression which are becoming new public health problems in the developed nations. Well- conducted clinical examinations with minimal possible investigations can bring down the cost of healthcare. And it will be a nice learning experience for the advancement of knowledge in medical science ultimately to the betterment of health of people all over the world. Competing interests: None declared
Measuring Quality of Care in a District Hospital – using a Lot Quality Assurance Sample of In-patient Records 28 September 2004
Bernhard Gaede, Medical Officer Emmaus Hospital, KwaZulu-Natal 3340, South Africa Send response to journal: Re: Measuring Quality of Care in a District Hospital – using a Lot Quality Assurance Sample of In-patient Records	The measurement of quality of care is crucial for the effective management of the health care service. Within the service it has particular significance to clinicians as it as it represents the output of their work, as well as to managers as it is the core product of the health care service. Measuring quality of care is difficult as the concept covers a wide spectrum of aspects, which includes the subjective experience of the patient, a relational component and more objective aspects of the service. The approach that is described audits the patient records, assuming that the record to some extent reflects the some of the objective aspects of the quality of the care given. It allows rapid determination whether targets for quality of care are being met or not, and therefore is a monitoring tool rather than measuring all aspects of care in depth. Lot Quality Assurance Sampling (LQAS) was developed in industry in the 1920’s as a rapid and reliable sample method to do quality control on products that were produced in large quantities. It is based on binomial statistics that require a much smaller random sample than descriptive statistical methods. Based on a small random sample from a lot, the whole lot was either accepted or rejected, depending on whether the quality target (‘decision rule’) was met or not. There is no estimation of the average quality of the lot that is assessed. However, the results from the individual lots can be added to give acceptably powered samples to give a determination of the average. LQAS has been applied in public health since the 1980’s where it has been used to assess whether health service targets have been met or not. The sample size at lot-level can be as small as 19 random samples, which is more manageable than the sample frames of most other methods. In community-based applications such as measuring immunization coverage, the results from individual lots at, for instance, sub-district level can be weighted and added to produce sufficient power to be able to calculate the average at District level. The principle of using collected data for information generation at different levels of the service has been one of the strengths over other rapid epidemiological methods (1). At a district level hospital in the Drakensberg in the KwaZulu-Natal Province of South Africa the possibility of using LQAS to measure the quality of care for inpatients was explored. Indicators were developed in a participatory way posing the question to doctors, nurses, the pharmacist and the administration: ‘Form the patient’s records, how could you tell that this patient received good care?’ Targets were arbitrarily set at 80% or 90% The data was collected by randomly selecting 19 in-patient records from all the admissions to the hospital in each month i.e. all patients that have been admitted in the hospital during one month represent a ‘lot’. The records from the patients were reviewed and scored by a team that included nurses, doctors, pharmacists and managers. Using available LQAS tables (1), the scores for each indicator assessed whether the set target had been met or not. The processes of doing the record reviews and scoring takes approximately 2 hours for each months assessment. After each monthly assessment, the results were fed back to the sections concerned and discussed how the performance could be improved. This led to a number of innovations and improvement of quality of care for patients, intensified supervision and support being instituted by the nursing staff and admin staff covering all wards. Every 6 months the averages for the past 6 months were calculated by adding the monthly results together to get a more long term view of what the level of care was. As an example of the results, a summary of the medical and pharmacy indicators for a period of 12 months is shown below. Targets reached? Jan Feb Mar April May Jun July Aug Sep Oct Nov Dec I Medical – target 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 1 History of presenting complaint Y Y Y Y Y Y Y Y Y Y Y Y 2 Basic examination Y Y Y Y Y Y Y Y Y Y Y Y 3 Plan related to assessment N N Y Y Y Y Y N Y Y Y Y 4 Investigations - problem orientated Y Y Y Y Y Y Y Y Y Y Y N 5 SOAP format N N Y Y Y Y Y N Y Y Y Y 6 Daily notes N Y Y N Y N Y Y Y Y Y Y