RESUMEN
BACKGROUND: User fees for primary care services were removed in rural districts in Zambia in 2006. Experience from other countries has suggested that health workers play a key role in determining the success of a fee removal policy, but also find the implementation of such a policy challenging. The policy was introduced against a backdrop of a major shortage in qualified health staff. METHODS: As part of a larger study on the experience and effect of user fee removal in Zambia, a number of case studies at the facility level were conducted. As part of these, quantitative and qualitative data were collected to evaluate health workers' satisfaction and experiences in charging and non-charging facilities. RESULTS: Our findings show that health-care workers have mixed feelings about the policy change and its consequences. We found some evidence that personnel motivation was higher in non-charging facilities compared to facilities still charging. Yet it is unclear whether this effect was due to differences in the user fee policy or to the fact that a lot of staff interviewed in non-charging facilities were working in mission facilities, where we found a significantly higher motivation. Health workers expressed satisfaction with an apparent increase in the number of patients visiting the facilities and the removal of a deterring factor for many needy patients, but also complained about an increased workload. Furthermore, working conditions were said to have worsened, which staff felt was linked to the absence of additional resources to deal with the increased demand or replace the loss of revenue generated by fees. CONCLUSION: These findings highlight the need to pay attention to supply-side measures when removing demand-side barriers such as user fees and in particular to be concerned about the burden that increased demand can place on already over-stretched health workers.
RESUMEN
OBJECTIVE: To investigate the availability and cost of essential medicines in health centres in rural Ethiopia, and to explore if the fee waiver system protects patients from having to pay for medicines. METHODS: The study took place in five health centres in rural Ethiopia. Availability and price of selected key essential medicines was established in the budget and special pharmacy of the health centre, as well as private outlets. Information on availability and cost of prescribed drugs was obtained through patient exit-interviews. RESULTS: Availability based of essential drugs at facility level was 91% based on a list of selected drugs vs. 84% based on prescriptions filled. However, less than half the prescribed drugs were obtained from the budget pharmacy, and one in six patients was forced to purchase drugs in the private sector, where drugs are roughly twice as expensive. The waiver system did not safeguard against having to pay for medicines. CONCLUSION: A revolving drug fund system in Ethiopia seems to improve availability of medicines, and can improve affordability by protecting people from purchasing drugs in the private sector. However, it may result in a parallel system, whereby the poor cannot access drugs if these are not available in the budget pharmacy. Equity is a concern in the absence of an adequate mechanism to protect the poor from catastrophic health expenditure.
Asunto(s)
Medicamentos Esenciales/provisión & distribución , Accesibilidad a los Servicios de Salud , Servicios Comunitarios de Farmacia , Costos de los Medicamentos , Medicamentos Esenciales/economía , Etiopía , Accesibilidad a los Servicios de Salud/economía , Humanos , Farmacias/economía , Sector Privado/economía , Servicios de Salud Rural/economía , Servicios de Salud Rural/provisión & distribuciónRESUMEN
Prepulse inhibition (PPI) refers to the attenuation of startle when a weak prestimulus precedes the startling stimulus. PPI is deficient in several psychiatric illnesses involving poor sensorimotor gating. Previous studies indicate that alpha1 adrenergic receptors regulate PPI, yet the extent to which these effects are mediated by central vs peripheral receptors is unclear. The present studies compared the effects of intracerebroventricular (ICV) vs intraperitoneal (IP) delivery of several alpha1 receptor agonists on PPI. Male Sprague-Dawley rats received either cirazoline (0, 10, 25, 50 microg/5 microl), methoxamine (0, 30, 100 microg/5 microl), or phenylephrine (0, 3, 10, 30 microg/5 microl) ICV immediately before testing. Separate groups received either cirazoline (0, 0.25, 0.50, 0.75 mg/kg), methoxamine (0, 2, 5, 10 mg/kg), or phenylephrine (0, 0.1, 2.0 mg/kg) IP 5 min before testing. PPI, baseline startle responses, and piloerection, an index of autonomic arousal, were measured. Cirazoline disrupted PPI; effective ICV doses were approximately six times lower than effective IP doses. Methoxamine disrupted PPI after ICV infusion but failed to affect PPI with IP doses that were up to 30-fold higher than the effective ICV dose. Phenylephrine disrupted PPI with ICV administration, but did not alter PPI after IP injection of even a 20-fold higher dose. None of the ICV treatments altered baseline startle magnitude, but phenylephrine and methoxamine lowered startle after administration of high systemic doses. Piloerection was induced by cirazoline via either route of administration, and by IP methoxamine and phenylephrine, but not by ICV infusion of methoxamine or phenylephrine. These findings indicate that alpha1 receptor-mediated PPI disruption occurs exclusively through stimulation of central receptors and is dissociable from alterations in baseline startle or autonomic effects.
Asunto(s)
Infusiones Parenterales , Inyecciones Intraventriculares , Inhibición Neural/fisiología , Receptores Adrenérgicos alfa 1/fisiología , Reflejo de Sobresalto/fisiología , Estimulación Acústica/métodos , Agonistas alfa-Adrenérgicos/administración & dosificación , Antagonistas Adrenérgicos alfa/administración & dosificación , Análisis de Varianza , Animales , Conducta Animal , Condicionamiento Clásico/efectos de los fármacos , Relación Dosis-Respuesta a Droga , Relación Dosis-Respuesta en la Radiación , Imidazoles/farmacología , Masculino , Metoxamina/farmacología , Inhibición Neural/efectos de los fármacos , Fenilefrina/farmacología , Piloerección/efectos de los fármacos , Prazosina/farmacología , Ratas , Ratas Sprague-Dawley , Reflejo de Sobresalto/efectos de los fármacosRESUMEN
RATIONALE: Prepulse inhibition (PPI) of the acoustic startle response is an operational measure of sensorimotor gating that can be assessed in both humans and animals. The noradrenergic system appears to play a role in PPI as the alpha1 agonist cirazoline disrupts PPI and the alpha1 antagonist prazosin blocks the disruptions in PPI produced by phencyclidine. OBJECTIVES: To better understand the role of adrenergic receptors in the modulation of PPI, we assessed the effects of the alpha2 adrenergic antagonist yohimbine (2.5, 5.0, and 7.5 mg/kg) on PPI. RESULTS: Yohimbine reduced PPI at the 5.0 and 7.5 mg/kg doses, without significantly affecting startle magnitude. In separate experiments, we examined whether adrenergic or serotonergic compounds blocked this disruption in PPI produced by yohimbine. There was a trend for the alpha2 agonist clonidine (0.01, 0.02 mg/kg) to attenuate the PPI disruption produced by yohimbine. However, other alpha2 agonists (guanfacine, medetomidine) and an alpha1 antagonist (prazosin) failed to prevent the disruption. The alpha2 antagonist atipamezole weakly decreased PPI in a narrow dose range (0.3-1.0 mg/kg). The 5-HT1A antagonist WAY100,635 (0.1, 0.3 mg/kg) significantly prevented the yohimbine-induced disruption of PPI. CONCLUSIONS: These findings indicate that (1) yohimbine disrupts PPI in rats and (2) the yohimbine-induced disruption of PPI is largely due to the 5-HT1A partial agonist properties of yohimbine.