RESUMEN
Improving the quality of obstetric care is an urgent priority in developing countries, where maternal mortality remains high. The feasibility of criterion-based clinical audit of the assessment and management of five major obstetric complications is being studied in Ghana and Jamaica. In order to establish case definitions and clinical audit criteria, a systematic review of the literature was followed by three expert panel meetings. A modified nominal group technique was used to develop consensus among experts on a final set of case definitions and criteria. Five main obstetric complications were selected and definitions were agreed. The literature review led to the identification of 67 criteria, and the panel meetings resulted in the modification and approval of 37 of these for the next stage of audit. Criterion-based audit, which has been devised and tested primarily in industrialized countries, can be adapted and applied where resources are poorer. The selection of audit criteria for such settings requires local expert opinion to be considered in addition to research evidence, so as to ensure that the criteria are realistic in relation to conditions in the field. Practical methods for achieving this are described in the present paper.
Asunto(s)
Auditoría Médica , Servicio de Ginecología y Obstetricia en Hospital/normas , Calidad de la Atención de Salud , Países en Desarrollo , Femenino , Ghana , Humanos , Jamaica , Pautas de la Práctica en Medicina , Embarazo , Complicaciones del Embarazo/terapiaRESUMEN
In a field study carried out in three rural communities in Paraguay in a zone endemic for Chagas disease, we implemented three different vector control interventions--spraying, housing improvement, and a combination of spraying plus housing improvement--which effectively reduced the triatomine infestation. The reduction of triatomine infestation was 100% (47/47) in the combined intervention community, whereas in the community where housing improvement was carried out it was 96.4% (53/55). In the community where fumigation alone was used, the impact was 97.6% (40/41) in terms of domiciliary infestation. In all the houses where an intervention was made, an 18-month follow-up showed reinfestation rates of less than 10%. A serological survey of the population in the pre- and post-intervention periods revealed a shift in positive cases towards older age groups, but no significant differences were observed. The rate of seroconversion was 1.3% (three new cases) in the community with housing improvement only, but none of these cases could have resulted from vector transmission. The most cost-effective intervention was insecticide spraying, which during a 21-month follow-up period had a high impact on triatomine infestation and cost US$ 29 per house as opposed to US$ 700 per house for housing improvement.
PIP: Chagas disease is most commonly spread by vectors in areas where inadequate housing, crowding, and poor hygienic conditions facilitate the proliferation of triatomines and help to maintain their domestic cycle. Chagas disease is widely distributed in America, from the southern US to southern Argentina, with a prevalence of 5-60%. In 3 rural communities in Paraguay in a zone endemic for Chagas disease, insecticide spraying, housing improvement, and a combination of spraying plus home improvement were implemented in a field study to control the vectors of Chagas disease. The insecticide applied was lambdacyhalothrin in a wettable powder formulation, while houses were modified to have smooth, flat, crack-free walls and ceiling surfaces, as well as better ventilation and illumination. Each intervention effectively reduced the vector of Chagas disease, with triatomine infestation reduced by 100% in the combined intervention community, 96.4% in the community in which only houses were improved, and 97.6% in terms of domiciliary infestation where only fumigation was used. In all houses in which an intervention was made, an 18-month follow-up showed reinfestation rates of less than 10%. A serological survey of the population during the pre- and post-intervention periods showed a shift in positive cases toward older age groups, but no significant differences were observed. The rate of seroconversion was 1.3% (3 new cases) in the community with housing improvement only, but none of those cases could have resulted from vector transmission. Insecticide spraying was the most cost-effective intervention: US$29 per house compared to US$700 per house for housing improvement.
Asunto(s)
Enfermedad de Chagas/prevención & control , Enfermedades Endémicas/prevención & control , Control de Insectos/métodos , Triatoma/parasitología , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Animales , Enfermedad de Chagas/epidemiología , Enfermedad de Chagas/parasitología , Enfermedad de Chagas/transmisión , Niño , Preescolar , Análisis Costo-Beneficio , Enfermedades Endémicas/estadística & datos numéricos , Femenino , Humanos , Lactante , Control de Insectos/economía , Masculino , Persona de Mediana Edad , Paraguay/epidemiología , Evaluación de Programas y Proyectos de Salud , Salud Rural , Estudios SeroepidemiológicosRESUMEN
PIP: This article presents a mid-course assessment on the National Mother Child Health (MCH) Insurance Program in Bolivia. Since the initiation of the MCH insurance program in 1996, the government anticipated the reduction of maternal and child mortality through provision of essential medical care for reproductive women, newborns and children under 5 years old. The program addresses priority health needs such as birth and antenatal care, acute respiratory illness, and diarrhea. The evaluation was conducted through interviews, information reviews, and surveys among 31 hospitals, health centers, and heath posts in 12 municipalities of Bolivia. Changes in the utilization of services, financial sustainability, and institutional capacity were observed as a result of insurance reform. In conclusion, this evaluation suggests some modifications in the program, including alteration of basic payment rates of the insurance program, creation of an administrative unit to manage program operations, and examination of problem areas such as subsidized transportation, reimbursement rates, shortage of working capital, and personnel incentives.^ieng
Asunto(s)
Protección a la Infancia , Estudios de Evaluación como Asunto , Seguro de Salud , Bienestar Materno , Centros de Salud Materno-Infantil , Organización y Administración , Evaluación de Programas y Proyectos de Salud , Investigación , Américas , Bolivia , Atención a la Salud , Países en Desarrollo , Economía , Administración Financiera , Salud , Servicios de Salud , América Latina , Atención Primaria de Salud , América del SurRESUMEN
The WHO is testing a new rationalised programme of antenatal care in a multicentre randomised trial. The motivation for this trial arose from the current uncertainty about the effectiveness of different approaches to provision of routine antenatal care. Decision makers also lack information about the costs of providing routine antenatal care and the cost-effectiveness of one programme over another. Such information will be needed before the final choice of programme can be made. The WHO trial provides an ideal opportunity to estimate and compare the incremental costs and cost-effectiveness of the new programme in four countries (Argentina, Cuba, Saudi Arabia, Thailand). A separate economic component has been organised to measure the costs of antenatal care. Methods for cost identification and measurement, and methods for economic analysis in the context of an international study are based on current recommendations for the conduct of economic evaluations alongside trials. However, several aspects require further development. In particular, this includes defining standard methods for costing in different countries; measuring women's costs of access to care; and making comparisons across international settings. The economic evaluation will also inform similar multicentre international trials and investigate issues of generalisability beyond trial settings.
PIP: Economic estimations at the technology assessment stage of health interventions permit early recognition of the relative efficiencies of health care interventions and allow those that are expensive and have limited health effects to be discouraged from widespread adoption. The World Health Organization (WHO) Antenatal Care Randomized Controlled Trial includes a component aimed at estimating the incremental costs and cost-effectiveness of a new rationalized program of prenatal care relative to those associated with the standard prenatal care package. 2400 pregnant women attending 53 clinics in Argentina, Cuba, Thailand, and Saudi Arabia have been enrolled. The central concern is that the new program of prenatal care does not result in higher overall costs to either the health care system or women receiving care than the currently practiced model. Resources included in the unit cost estimation are staff, drugs and medications, materials, equipment, vehicles, utilities, and buildings and land. Monthly costing data are being collected at all study sites in Cuba and Thailand over a 12-month period and a questionnaire has been developed to assess the costs borne by women. Data from these two sources will be collated to produce tables of costs at the health facility, country, and international levels. The reliability of the results should be enhanced by the association of the economic analysis with a carefully designed randomized trial intended to minimize bias in terms of differences in the quantities of services used.
Asunto(s)
Países en Desarrollo , Costos de la Atención en Salud/estadística & datos numéricos , Investigación sobre Servicios de Salud/métodos , Estudios Multicéntricos como Asunto/métodos , Atención Prenatal/economía , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Organización Mundial de la Salud , Argentina , Análisis Costo-Beneficio , Cuba , Femenino , Humanos , Embarazo , Arabia Saudita , TailandiaRESUMEN
Cost-effectiveness analysis indicates that some water supply and sanitation (WSS) interventions are highly cost-effective for the control of diarrhoea among under-5-year-olds, on a par with oral rehydration therapy. These are relatively inexpensive "software-related" interventions such as hygiene education, social marketing of good hygiene practices, regulation of drinking-water, and monitoring of water quality. Such interventions are needed to ensure that the potentially positive health impacts of WSS infrastructure are fully realized in practice. The perception that WSS programmes are not a cost-effective use of health sector resources has arisen from three factors: an assumption that all WSS interventions involve construction of physical infrastructure, a misperception of the health sector's role in WSS programmes, and a misunderstanding of the scope of cost-effectiveness analysis. WSS infrastructure ("hardware") is generally built and operated by public works agencies and financed by construction grants, operational subsidies, user fees and property taxes. Health sector agencies should provide "software" such as project design, hygiene education, and water quality regulation. Cost-effectiveness analysis should measure the incremental health impacts attributable to health sector investments, using the actual call on health sector resources as the measure of cost. The cost-effectiveness of a set of hardware and software combinations is estimated, using US$ per case averted, US$ per death averted, and US$ per disability-adjusted life year (DALY) saved.
PIP: Cost-effectiveness analysis indicates that some water supply and sanitation (WSS) interventions are very cost-effective in controlling diarrhea among children under age 5 years, as cost-effective as oral rehydration therapy. These include relatively inexpensive interventions such as hygiene education, the social marketing of good hygiene practices, regulation of drinking water, and monitoring of water quality. Such interventions are needed to ensure that the potentially positive health impacts of WSS infrastructure are fully realized in practice. The perception that WSS programs are not cost-effective has grown out of the assumption that all WSS interventions involve building physical infrastructure, a misperception of the health sector's role in WSS programs, and a misunderstanding of the scope of cost-effectiveness analysis. WSS infrastructure is usually built and operated by public works agencies and financed by construction grants, operational subsidies, user fees, and property taxes. Health sector agencies should provide project design, hygiene education, and water quality regulation. The cost-effectiveness of various water and sanitation interventions to control childhood diarrhea is estimated, using US$ per case averted, US$ per death averted, and US$ per disability-adjusted life year saved.
Asunto(s)
Diarrea Infantil/prevención & control , Diarrea/prevención & control , Saneamiento , Abastecimiento de Agua , Preescolar , Cólera/prevención & control , Computadores , Análisis Costo-Beneficio , Diarrea/terapia , Diarrea Infantil/terapia , Fluidoterapia/economía , Educación en Salud , Planificación en Salud , Política de Salud , Humanos , Higiene , Lactante , Recién Nacido , México , Modelos Teóricos , Salud Pública , Saneamiento/economía , Programas Informáticos , Abastecimiento de Agua/economíaRESUMEN
PIP: This article discusses the integration of sexually transmitted disease (STD) care within family planning (FP) programs and the cost effectiveness of integrated services in development countries. Examples are taken from experiences in Colombia, India, the US, and Kenya. The 1994 International Conference on Population and Development urged the integration of reproductive health care within FP. The more than 330 million annual new STD cases increase HIV transmission and cause pain and infertility. Women are biologically more susceptible to STDs, are more likely to be asymptomatic, and face harsher consequences, including death. Women with STDs should avoid the IUD and use barrier methods. Maintaining laboratories, training staff, and supplying drugs can overburden strained health budgets, but may lower long-term medical costs, increase productivity in employment, and decrease pain and suffering. STDs are viewed by some US health professionals as a "best buy" for being one of the least expensive of the reproductive health options. A Kenyan study found that treating STDs and providing oral contraceptives saved money by collapsing treatment into one instead of two visits. The savings were in overhead and staff costs. Evaluations of cost effectiveness should consider local STD prevalence, cultural setting, client needs, and available resources. In some cases, referral of cases to STD clinics may be the most cost-effective. A US study found that chlamydia screening for all FP clients was more cost-effective than screening selectively. Another US study found that universal screening for chlamydia would provide long-term medical savings even if prevalence was only 2%. Developing countries have the lower-cost option of offering syndromic management of STDs for symptomatic women rather than lab tests. A program in India cut costs by educating and encouraging barrier methods.^ieng
Asunto(s)
Análisis Costo-Beneficio , Países en Desarrollo , Planificación en Salud , Servicios de Salud , Enfermedades de Transmisión Sexual , África , África del Sur del Sahara , África Oriental , Américas , Asia , Colombia , Atención a la Salud , Países Desarrollados , Enfermedad , Estudios de Evaluación como Asunto , Servicios de Planificación Familiar , Salud , India , Infecciones , Kenia , América Latina , América del Norte , Organización y Administración , América del Sur , Estados UnidosRESUMEN
OBJECTIVE: The United Nations Human Development Index (HDI) is a composite index of life expectancy, literacy, and per capita gross domestic product that measures the socioeconomic development of a country. We estimated infant and maternal mortality rates in the world and assessed how well the HDI and its individual components predicted infant and maternal mortality rates for individual countries. MATERIALS: Data on mortality rates and values for HDI components were obtained from the United Nations and the World Bank. RESULTS: For the 1987 to 1990 period, approximately 9 million infant deaths and 349,000 maternal deaths occurred in the world annually, yielding global infant and maternal mortality rates of 67 per 1000 and 250 per 100,000 live births, respectively. HDI is a powerful predictor of both infant and maternal mortality rates. It accounts for 85% to 92% of the variation in infant mortality rates, and 82% to 85% of the variation in maternal mortality rates among countries. Each component of HDI is also strongly correlated with both infant and maternal mortality rates (significance of all values for r, p < 0.001), and eliminating life expectancy from HDI does not decrease significantly the predictive power of HDI for infant or maternal mortality rates. CONCLUSION: HDI is not only a useful measure for socioeconomic development, but also a powerful predictor of infant and maternal mortality rates for individual countries.
PIP: The UN Human Development Index (HDI), a composite index of life expectancy, literacy, and per capita gross domestic product, provides a measure of a country's level of socioeconomic development. An analysis of mortality data obtained from the United Nations and the World Bank indicated that the HDI is, in addition, a powerful predictor of infant and maternal mortality rates. The 1990 infant mortality rate in the 78 countries for which data were available ranged from 5/1000 live births in Japan to 143/1000 live births in Bhutan and Gambia; the maternal mortality rate ranged from 3/100,000 live births in Finland to 1500/100,000 live births in Nepal. The HDI accounted for 85-92% of the variance in infant mortality rates and 82-85% of that in maternal mortality. Although life expectancy tended to be the HDI component with the strongest predictive power, especially for infant mortality, the explanatory power of the index did not decrease significantly even when this component was excluded. If infant and mortality rates in developed countries in 1987-90 had prevailed worldwide, 8 million infant and 340,000 maternal deaths would have been averted each year.
Asunto(s)
Países Desarrollados , Países en Desarrollo , Economía , Desarrollo Humano , Mortalidad Infantil , Mortalidad Materna , Adolescente , Adulto , Anciano , Estudios Transversales , Escolaridad , Femenino , Humanos , Recién Nacido , Esperanza de Vida , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Factores Socioeconómicos , Naciones UnidasRESUMEN
An increase in exclusive breastfeeding prevalence can substantially reduce mortality and morbidity among infants. In this paper, estimates of the costs and impacts of three breastfeeding promotion programmes, implemented through maternity services in Brazil, Honduras and Mexico, are used to develop cost-effectiveness measures and these are compared with other health interventions. The results show that breastfeeding promotion can be one of the most cost-effective health interventions for preventing cases of diarrhoea, preventing deaths from diarrhoea, and gaining disability-adjusted life years (DALYs). The benefits are substantial over a broad range of programme types. Programmes starting with the removal of formula and medications during delivery are likely to derive a high level of impact per unit of net incremental cost. Cost-effectiveness is lower (but still attractive relative to other interventions) if hospitals already have rooming-in and no bottle-feeds; and the cost-effectiveness improves as programmes become well-established. At an annual cost of about 30 to 40 US cents per birth, programmes starting with formula feeding in nurseries and maternity wards can reduce diarrhoea cases for approximately $0.65 to $1.10 per case prevented, diarrhoea deaths for $100 to $200 per death averted, and reduce the burden of disease for approximately $2 to $4 per DALY. Maternity services that have already eliminated formula can, by investing from $2 to $3 per birth, prevent diarrhoea cases and deaths for $3.50 to $6.75 per case, and $550 to $800 per death respectively, with DALYs gained at $12 to $19 each.
PIP: During April 1992 to March 1993, in Santos, Brazil, in San Pedro Sula, Honduras, and in Mexico City, Mexico, interviews were conducted with 200-400 women in each of three hospitals and at their homes at 1 month and at 2-4 months postpartum as part of a study of the cost and effectiveness of three breast feeding promotion programs in hospital-based maternity services. The hospital in Mexico and, in the past, the one in Brazil used infant formula, while the hospital in Honduras and the hospital in Brazil removed infant formula. Various nutrition and policy specialists estimated the costs and impacts of these programs to develop cost effectiveness measures and then compared them with other health interventions. At a net incremental cost ranging from about US$0.30 to US$0.40 per birth, infant feeding programs with formula feeding in nurseries and maternity wards can reduce diarrhea cases for about US$0.65 to US$1.10 each, prevent diarrhea-related deaths for US$100 to US$200 each, and reduce the burden of disease for about US$2 to US$4 per disability-adjusted life year (DALY). On the other hand, by investing US$2 to US$3 per birth, maternity services that no longer provide infant formula can prevent diarrhea cases and deaths for US$3.50 to US$6.75 per case and US$550 to US$800 per death, respectively, and gain DALYs at a cost of US$12 to US$19 each. The estimates obtained indicate that breast feeding promotion in hospitals competes very closely with measles and rotavirus vaccination as the most efficient option for diarrheal disease control and is markedly more cost-effective than oral rehydration therapy and cholera immunization even when infant formula is no longer offered. In fact, investments in breast feeding promotion are among the most cost-effective health interventions. The cost effectiveness of breast feeding promotion programs improved as programs became institutionalized. These findings show that such programs are a very efficient way of improving the health status of children.
Asunto(s)
Lactancia Materna , Prioridades en Salud , Promoción de la Salud/organización & administración , Programas Nacionales de Salud/organización & administración , Adulto , Brasil/epidemiología , Análisis Costo-Beneficio , Diarrea/epidemiología , Diarrea/mortalidad , Diarrea/prevención & control , Femenino , Implementación de Plan de Salud , Promoción de la Salud/economía , Honduras/epidemiología , Humanos , Mortalidad Infantil , Recién Nacido , México/epidemiología , Morbilidad , Programas Nacionales de Salud/economía , Desarrollo de Programa/economía , Años de Vida Ajustados por Calidad de VidaRESUMEN
PIP: In developing countries skin disease prevalences may affect over 60% of the community and are often poorly managed. The impact of ineffective treatment of skin disease on family life in rural Mexico was investigated. In the community of Cayaco, a house to house questionnaire survey was conducted to study the distribution of skin disease and the use and cost of treatments. The diagnosis of skin lesions was validated by physical examination and in a separate random survey in 120 primary school children. Regression analysis was carried out. 380 households with 1528 people (713 males, 815 women) were surveyed, of whom 207 reported skin disease. 131 attended the outpatient clinic (41 males, 90 females). The commonest skin disease among them was pyoderma (27 patients), followed by scabies (26), pityriasis alba (23), acne (8), dermatophytosis (8), viral warts (8), and pediculosis capitis (8). 66 had other skin conditions ranging from urticaria (2) to scrofuloderma (1). 58 patients had more than one condition, a total of 189 dermatoses. Six conditions accounted for 102 of the dermatoses. 15 patients with scabies and 21 with pyoderma had received ineffective treatment over the previous six months at a mean cost of 66 new pesos and 136 new pesos, respectively. Many of the affected children had missed school: eight days for scabies (12 patients) and 15 days for pyoderma (10 patients). 68 of the 120 primary school children in the random survey had at least one treatable skin condition. In half of the households people had symptoms, and 57% of the children had at least one treatable skin disease. The mean total cost of ineffective treatment for the two commonest conditions over six months was a major financial burden on families where the mean daily wage was 15.2 new pesos. Both diseases are readily curable by eliminating scabies. In the area a new system of community dermatology is implemented with close collaboration between specialists and primary health care workers.^ieng
Asunto(s)
Costo de Enfermedad , Enfermedades de la Piel/economía , Absentismo , Femenino , Humanos , Masculino , México , Salud Rural , Enfermedades de la Piel/terapia , Insuficiencia del TratamientoRESUMEN
PIP: In an interview Dr. Ricardo Bressani, a chemical engineer by profession and a consultant of the Institute of Nutrition of Central America and Panama (INCAP), talks about the search for a product later given the name of Incaparina, which was eventually developed for food supplementation programs by INCAP. Experiments were made with soybeans, cottonseed, and various cereals to arrive at the optimal mixture of 62% cereal and 38% protein for this product. In addition, vitamins and lysine were added. The major demand for this biscuit occurred between 1976 and 1978. Since that time sales have ebbed partly owing to the soaring commodity prices. Incaparina is sold in Guatemala and El Salvador and there are tests going on in Mexico, Colombia, and Cuba to produce it locally. This product is also proof of the benefit of developing leguminous cereal systems. The optimal combination is 70% cereals and 30% legumes, each providing 50% protein. The potential of mixing various other cereals and fruits are also being studied. A large number (up to 60 annually) of nutritional research papers are published on the national level and in Latin America in prestigious scientific journals whose monitoring calls for coordination between different authors.^ieng
Asunto(s)
Análisis Costo-Beneficio , Suplementos Dietéticos , Abastecimiento de Alimentos , Trastornos Nutricionales , Investigación , Américas , América Central , Conservación de los Recursos Naturales , Atención a la Salud , Países en Desarrollo , Enfermedad , Economía , Ambiente , Estudios de Evaluación como Asunto , Guatemala , Salud , Planificación en Salud , Servicios de Salud , América Latina , América del Norte , Atención Primaria de Salud , TecnologíaRESUMEN
PIP: Rural areas in developing countries have no hope of benefiting from electricity generation programs because of a lack of resources. Currently the common practice is to use kerosene lamps for light, disposable batteries for radios, and auto batteries for television. The auto battery must be hauled by pack animal to a charging station. An alternative that is growing in popularity is the installation of photovoltaic (PV) systems in each house. The advantages include very low operating costs (sunshine is free), long life (PV cells last 20 years), they can be installed in any home without regard for power grids. The biggest disadvantage is very high initial cost. To solve this problem many programs have been developed to finance systems. Enersol Associates started with $10,000 seed money and developed a loan program that has helped bring electricity to 1500 homes in the Dominican Republic. The Solar Electric Light and Fund started with $150,000 and has brought electricity to 3500 homes in Sri Lanka. The United Nations Development Program gave $7 million to Zimbabwe to fund a project that is expected to bring electricity to 20,000 homes over the next 5 years.^ieng
Asunto(s)
Análisis Costo-Beneficio , Países en Desarrollo , Fuentes Generadoras de Energía , Composición Familiar , Gastos en Salud , Tecnología , Naciones Unidas , África , África del Sur del Sahara , África Oriental , Américas , Asia , Región del Caribe , Conservación de los Recursos Naturales , República Dominicana , Economía , Ambiente , Estudios de Evaluación como Asunto , Administración Financiera , Agencias Internacionales , América Latina , América del Norte , Organizaciones , Sri Lanka , ZimbabweRESUMEN
PIP: An evaluation of the Jamaican Women's Center Programme by the Population Council of New York found that 55% of teenage mothers in Jamaica returned to school in Kingston and 73% in the Mandeville branch following their pregnancies and exposure to the program. Only 15% who were not exposed to the program returned to school. The Sister School Workshop Program on Teenage Pregnancy provides knowledge instead of the myth and fantasy given by parents and clergy. Continuing education is particularly important for those with low self-esteem. The Center also provided knowledge about contraception. The findings were that contraceptive use was 89% among program graduates and 81% among nonprogram persons. In addition to the higher % of usage, there were differences in methods used. Center users preferred the IUD and pills, while nonprogram persons favored pills and injections. Subsequent pregnancies were much higher among nonprogram persons at 39%, while for program participants 15% at Kingston and 8% from the Mandeville Center had subsequent pregnancies within 3 years. The creation of the Jamaican Women's Center in 1978 has also promoted continuing education during pregnancy. Assistance is also provided to those reentering the school system after giving birth. The financial cost has been reasonable at J$3500 program year/woman and nursery facility costs at J$664/child/year. Other services to former students include counseling and school visits and occasionally financial aid amounts J$176/woman/year. Rural outreach averages J$336/woman/year. The identifiable weakness was in preparation of these girls for employment. It is suggested that additional efforts be made to provide wider and more marketable skills to meet local needs. There is also a need to provide linkage with other skills training programs and small business groups in order to expand labor force opportunities for these women.^ieng
Asunto(s)
Conducta Anticonceptiva , Análisis Costo-Beneficio , Consejo , Escolaridad , Empleo , Embarazo en Adolescencia , Evaluación de Programas y Proyectos de Salud , Proyectos de Investigación , Educación Sexual , Instituciones de Atención Ambulatoria , Américas , Región del Caribe , Anticoncepción , Demografía , Países en Desarrollo , Economía , Educación , Estudios de Evaluación como Asunto , Servicios de Planificación Familiar , Fertilidad , Planificación en Salud , Jamaica , América del Norte , Organización y Administración , Población , Dinámica Poblacional , Investigación , Conducta Sexual , Clase Social , Factores SocioeconómicosRESUMEN
"The present article...reviews the major findings of the end-evaluation of the EEC-IOM project in Central America, the Dominican Republic and Panama, a five-year scheme funded by the Commission of the European Communities (EEC) and implemented by the International Organization for Migration (IOM), to promote a selective and development-oriented return of Latin American professionals to Costa Rica, the Dominican Republic, Honduras, Nicaragua and Panama.... The core objectives of this evaluation, undertaken in September-December 1989, were to assess the project's contribution to local socioeconomic, scientific and technological development through the selective supply of expatriate professionals to developing institutions operating in so-defined priority areas; to identify the returnees' personal reintegration patterns at the professional, socioeconomic and family-related levels; and to measure the project's cost effectiveness." (SUMMARY IN FRE AND SPA)
Asunto(s)
Análisis Costo-Beneficio , Economía , Emigración e Inmigración , Empleo , Etnicidad , Motivación , Evaluación de Programas y Proyectos de Salud , Factores Socioeconómicos , Américas , Región del Caribe , América Central , Costa Rica , Demografía , Países en Desarrollo , República Dominicana , Estudios de Evaluación como Asunto , Honduras , América Latina , Nicaragua , América del Norte , Organización y Administración , Panamá , Población , Características de la Población , Dinámica Poblacional , Política Pública , Clase SocialRESUMEN
In an era of decreasing availability of funds and increasing demand, the AIDS epidemic threatens to overwhelm health-care services in some countries. We describe a comprehensive model for the treatment of AIDS in San Juan, Puerto Rico, and compare it with traditional hospital-based services. Given the existing allocation of funds, the comprehensive model emphasised prevention, education, surveillance, early detection, and outpatient care to reduce hospital care. In 1987, the last year of the traditional system, there were 95 admissions of AIDS patients to hospital, and in 1988, the first year of the comprehensive model, there were 100 admissions. The mean length of stay of AIDS inpatients was reduced from 22.3 days in 1987 to 11.3 days in 1988, a 46.8% reduction (p = 0.001). The annual mean (SE) cost of inpatient care per AIDS patient fell from $15,118 (1699) in 1987 to $3869 (659) in 1988. Savings were used to improve non-hospital services, including outreach, education, emergency and outpatient care, laboratory and epidemiological services, and research, and to introduce an employee incentive scheme. Management strategies that reduce the length of inpatient care and provide less costly treatment alternatives can improve AIDS health care in developing nations.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/economía , Atención a la Salud/economía , Síndrome de Inmunodeficiencia Adquirida/epidemiología , Síndrome de Inmunodeficiencia Adquirida/prevención & control , Síndrome de Inmunodeficiencia Adquirida/terapia , Adulto , Preescolar , Servicios Contratados/economía , Análisis Costo-Beneficio , Atención a la Salud/normas , Grupos Diagnósticos Relacionados/economía , Femenino , Educación en Salud/economía , Humanos , Tiempo de Internación/economía , Masculino , Evaluación de Programas y Proyectos de Salud , Puerto Rico/epidemiología , Índice de Severidad de la EnfermedadRESUMEN
PIP: Voluntary sterilization is the chosen family planning method of more couples worldwide than any other, evidence of its acceptability and lack of serious shortcomings. This work offers observations on training, counseling, supervision, cost-effectiveness, and acceptability of voluntary sterilization programs, and presents some results of Profamilia's program. Training of qualified medical personnel in the available techniques is a relatively simple. Profamilia has trained almost 1000 medical professionals, nearly half of whom were from other countries, but a legal technicality has forced Profamilia to curtail training of foreign professionals. It is much more difficult to train personnel to identify and inform potential clients about sterilization, promote the procedure, and provide follow-up, yet these program activities are crucial to a successful sterilization program. Counseling of couples is necessary and should include discussion of the greater convenience of vasectomy compared to tubal ligation. Sterilization should be presented as a permanent method. This permanence, often viewed as a disadvantage, has a positive side in freeing couples of the need for further consideration of family size or contraception and in protecting them against family and social pressures to have more children. Raising marriage age or family size requirements in the hope of avoiding regret does not appear justified. Assuring that sterilization is truly voluntary is a preoccupation of donors, but has not been a problem in Profamilia programs. All clients are required to make some payment and to sign a detailed consent form. Profamilia has been persuaded to discourage mental defectives from undergoing sterilization because of possible legal problems. Periodic, unannounced visits to clinics are recommended for quality control and supervision. Profamilia employs salaried medical personnel for sterilization when careful supervision is available to ensure that they do not unjustifiably reject applicants, and pays on a per-case basis otherwise. It is estimated that each Profamilia sterilization provides 12.5 couple-years of protection. Each sterilization costs US $ 33.20 on average, 60% of it for personnel costs. Profamilia offer highly subsidized services for its lower middle class clients and almost free services for its poorest 40% of clients. The financial strain is considerable for Profamilia, which carries out some 70,000 sterilizations each year at a cost of US $ 2.25 million, only 1/7 of it directly paid for by clients. Since 1973, Profamilia has performed over 700,000 tubal ligations. There have been 19 deaths, 9 attributed to surgical and 5 to anesthetic problems. There are minor complications in about 1% of cases. 26,401 vasectomies were performed through 1990, with 2 cases requiring hospitalization.^ieng
Asunto(s)
Análisis Costo-Beneficio , Consejo , Educación , Emociones , Planificación en Salud , Administración de los Servicios de Salud , Consentimiento Informado , Organización y Administración , Aceptación de la Atención de Salud , Administración de Personal , Evaluación de Programas y Proyectos de Salud , Esterilización Reproductiva , Esterilización Tubaria , Enseñanza , Vasectomía , Instituciones de Atención Ambulatoria , Américas , Conducta , Colombia , Anticoncepción , Conducta Anticonceptiva , Países en Desarrollo , Estudios de Evaluación como Asunto , Servicios de Planificación Familiar , América Latina , Psicología , América del SurRESUMEN
In 1983, we implemented an ongoing perinatal mortality audit in Guadeloupe to identify factors underlying the current level of poor perinatal outcome and to stimulate increased provider motivation. The audit was part of an active research approach to document the specific nature of the perceived perinatal health problem, to modify provider behavior through the use of this acquired information, and, ultimately, to decrease avoidable perinatal deaths. We investigated all 320 perinatal deaths in Guadeloupe during 1984 and 1985. Nearly one-half of the perinatal deaths reviewed were determined to be related to maternal high blood pressure, maternal/fetal infection, and preterm delivery. Slightly more than one-half of the perinatal deaths were considered to be avoidable. Over the course of the audit, perinatal mortality rates exhibited a marked decline. The findings of this study support claims that perinatal audits with confidential inquiries may help effect change in perinatal health status in a population; the findings also call attention to the potential benefits of incorporating motivational incentives into these activities.
PIP: In 1983, the authors implemented an ongoing perinatal mortality audit in Guadeloupe to identify factors underlying the current level of poor perinatal outcome and to stimulate increased provider motivation. The audit was part of an active research approach to document the specific nature of the perceived perinatal health problem, to modify provider behavior through the use of this acquired information, and, ultimately, to decrease avoidable perinatal deaths. The authors investigated all 320 perinatal deaths in Guadeloupe during 1984-85. Nearly 1/2 of all perinatal deaths reviewed were determined to be related to maternal high blood pressure, maternal/fetal infection, and preterm delivery. Slightly more than 1/2 of the perinatal mortality rates exhibited a marked decline. The findings of this study support claims that perinatal audits with confidential inquiries may help effect change in perinatal health status in a population; the findings also call attention to the potential benefits of incorporating motivational incentives into these activities.
Asunto(s)
Mortalidad Infantil , Auditoría Médica/organización & administración , Causas de Muerte , Anomalías Congénitas/prevención & control , Femenino , Sufrimiento Fetal/prevención & control , Humanos , Recién Nacido de Bajo Peso , Recién Nacido , Masculino , Indias OccidentalesRESUMEN
The findings of three surveys and three studies used by Profamilia to evaluate and improve their voluntary female sterilization program are presented. The surveys measured sociodemographic characteristics of users, factors behind the sterilization decision, and user satisfaction with the operation in the short run and over time. The studies explored methodologies for more accurate cost-effectiveness analysis. Results of the projects were used by Profamilia management to identify areas of program strengths and weaknesses and to implement operational changes.
PIP: Profamilia is a nonprofit, private family planning organization based in Bogota, Colombia. To improve program performance, the findings of 3 surveys and 3 studies were used by Profamilia to evaluate and improve their female sterilization (FS) program. The surveys measured socio- demographic characteristics of users, factors behind the sterilization decision, and user satisfaction with the operation in the short run and over time. The studies explored methodologies for more accurate cost- effectiveness analysis. Results of the projects were used by the Profamilia movement to identify areas of program strengths and weaknesses and to implement operational changes. In 1970, Profamilia offered vasectomy; FS was offered in 1972. The vasectomy program was ineffective; however, FS was very successful. Approximately 72% of all procedures performed in Colombia are done by Profamilia. In 1972, 2 Colombian gynecologists, (1 from Colombia) were trained in Colombia to do FSs by doctors from Johns Hopkins Hospital. At present, Profamilia uses about 40 doctors directly, and contracts with others. Program evaluation is done by using cost-effectiveness evaluation to measure financial efficiency, survey analysis to measure general program efficiency and client satisfaction, and collection of service statistics to measure program output. The 1st survey was done in 1976 and 1977 to learn about user characteristics. The 2nd project was a 2-phase (retrospective-prospective) survey carried out in 1978-83. In 1985, Profamilia decided to do a follow-up survey in conjunction with Association for Voluntary Surgical Conception (AVSC). It emphasized factors influencing the decision to be sterilized. Sterilization acceptors were interviewed in 8 clinics in a nonrandom sample. 3 cost- effectiveness studies have been done on Profamilia's FS program. A departmental study determined the cost per couple year of protection offered by the 5 service departments of Profamilia; an accounting study determined the full unit cost per sterilization; and an organization-wide cost study determined how to assign indirect and shared costs of support divisions to service departments like sterilization.
Asunto(s)
Servicios de Planificación Familiar/organización & administración , Esterilización Reproductiva , Adulto , Colombia , Costos y Análisis de Costo , Consejo/métodos , Estudios de Evaluación como Asunto , Servicios de Planificación Familiar/economía , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Persona de Mediana Edad , Educación del Paciente como Asunto/organización & administración , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
Operations research is the study of factors that can be controlled by program administrators. Among such factors is the frequency of performing program activities. The present experiment, conducted in Lima, Peru during 1985-86, tested the impact of holding family planning post sessions once per month, twice per month, and weekly. Frequency was shown to have a major impact on program outputs, costs, and cost-effectiveness. Depending on the indicator, sessions held twice per month produced between 1.5 and 2.1 times the output of those conducted once per month. Weekly sessions produced between 1.3 and 1.6 times the output of those held twice per month. At an output level of nearly 11,200 visits per year, twice-per-month sessions were estimated to be 7-38 percent more cost-effective, depending on the indicator, than once-per-month sessions, and 6-28 percent more cost-effective than weekly sessions.
PIP: Operations research is the study of factors that can be controlled by program administrators. One of these factors is the frequency of performing program activities. The operational variable is the frequency of having clinical sessions in medical back-up posts in a community-based distribution (CBD) program in Lima, Peru. The study covered 42 posts in urban marginal areas of Lima. 3 performing frequencies were compared: 1) once a month; 2) twice a month; and 3) weekly. A randomized block design was used. The study lasted 12 months--from August, 1985-July, 1986. 3 output indicators were chosen: 1) effectiveness; 2) efficiency; and 3) cost-effectiveness. Outputs include program acceptors, total visits, IUD insertions, sessions and family planning (FP) visits. The once-per-month posts finished 98% of scheduled sessions while the twice-a-month and weekly sessions finished 97% and 96%, respectively. Mean duration of the clinic sessions held by the monthly and twice-monthly posts was 2.9 hours (s.d.=.84 and .73, respectively). Mean duration for the weekly group was 2.8 hours (s.d.=.67). About 73% of the FP talks scheduled for the monthly post were really accomplished compared to 66% for the twice-monthly and weekly groups. The 42 posts held 1136 clinic sessions during the year and had 11,196 visits, including 5371 FP visits. 1705 women accepted a FP method at the posts. 77% were IUD takers; 15% chose pills; and 8% accepted barrier methods. There were 4768 IUD visits. There were 414 pill visits and 18% barrier method visits. About 89% of all FP visits were IUD-related. 87% of all IUD insertions were referred by CBD workers and 5% by supervisors. There were 2954 total visits in monthly posts; 3501 in twice-monthly; and 5641 in weekly posts. Output went up linearly with session frequency, but in lesser proportion than the rise in the number of sessions held. Differences are statistically significant for all outputs. Twice-a-month posts had 1.5-2.1 times the output of once-a-month posts; weekly posts had about 1.3-1.6 times the output as twice-a-month posts, depending on the variable chosen. With output level of nearly 11,200 visits per year, twice-a-month sessions were estimated to be 7-38% more cost-effective than once-a-month sessions; 6-28% more cost-effective than weekly sessions.
Asunto(s)
Atención a la Salud/métodos , Servicios de Planificación Familiar/organización & administración , Servicios de Salud Comunitaria/economía , Servicios de Salud Comunitaria/organización & administración , Análisis Costo-Beneficio , Atención a la Salud/economía , Femenino , Humanos , Investigación Operativa , Perú , Salud UrbanaRESUMEN
The treatment received by children aged under 5 years with diarrhoea was studied in the Hospital Infantil de México (Federico Goméz), Mexico City. The costs of treatment were calculated and estimates were made of how these had changed since the establishment of an oral rehydration unit in the hospital in 1985. The results indicate that drug treatment of outpatients was generally appropriate and inexpensive. In contrast, the cost of drugs for inpatients was considerably higher. The seriousness of the cases justified much of this additional expense for inpatients, but there is evidence that the costs could be reduced further without jeopardizing the quality of the care. Diagnostic tests were relatively expensive, frequently failed to identify diarrhoeal etiology, and their results correlated poorly with the treatment prescribed. The oral rehydration unit resulted in significant savings by causing a 25% fall in the number of inpatients with diarrhoea.
PIP: Treatments of diarrhea in children under 5 by the Hospital Infantil de Mexico (Federico Gomez), Mexico City, in 1983-84 versus 1986 were compared with respect to drugs and laboratory tests, and costs were estimated. An outpatient oral rehydration unit was opened in the emergency room, reducing by 25% numbers of inpatients with diarrhea. Other than increased use of ORS, no changes in hospitalized patients were evident except a trend toward more laboratory tests, and prescription of amoxicillin and chloramphenicol over amikacin. There was little evidence that laboratory tests or antibiotic prescriptions were appropriate in most cases. Only 1 patient had a positive Shigella culture, and those with negative fecal cultures received more antibiotics than those with no cultures taken. Intravenous solutions were used in 85%, while only 17% were dehydrated and 22% had electrolyte imbalances, possibly because as a method of rehydration they require less nursing time than oral solutions. The average patient costs were 1200 pesos for lab tests and 180 pesos for drugs. In addition, prior to hospitalization, many patients had received ineffective or dangerous drugs such as Kaopectate-antibiotic mixtures, intestinal motility agents such as loperamide, Lactobacillus cultures, and iodochlorohydroxyquinoline.
Asunto(s)
Diarrea/economía , Quimioterapia/economía , Fluidoterapia/economía , Antidiarreicos/uso terapéutico , Preescolar , Diarrea/tratamiento farmacológico , Diarrea/terapia , Femenino , Hospitales Pediátricos , Humanos , Lactante , Masculino , MéxicoRESUMEN
A national household coverage survey of 3697 Ecuadorean children, carried out in July 1986, provided an opportunity for a cost-effectiveness analysis of (1) routine vaccination services based in fixed facilities and (2) mass immunization campaigns. A major purpose of the campaigns was to complement the routine services and to accelerate immunization activities. Based on the coverage survey, the Program for Reduction of Maternal and Childhood Illness (PREMI) and earlier campaigns increased the proportion of children under 5 years who were fully vaccinated from 43% to 64%. In one year, the PREMI campaign was responsible for fully vaccinating 11% of children under one year, 21% of 1-2-year-old children, and 13% of all children under 5 years. The campaign also helped ensure that vaccinations were completed when children were still very young and at greatest risk. The average cost per vaccination dose (in 1985 US$ prices) was approximately $0.29 for fixed facilities and $0.83 for the PREMI campaign. Total national costs were $675,000 and $1,665,000 for routine and campaign services respectively. The cost per fully vaccinated child (FVC) was $4.39 for routine vaccination services and $8.60 for the campaign. The cost per death averted was about $1900 for routine vaccination services, $4200 for the PREMI campaign, and $3200 for the combined programme. Because of Ecuador's lower mortality rates, the costs per death averted in Ecuador from both vaccination strategies are not as low as those from studies of vaccinations in Africa. The campaigns, though less cost-effective than routine services, significantly improved the vaccination coverage of younger children who had been missed by the routine services. The costs per FVC of both the campaign and the routine services compare favourably with such programmes in other countries.