BACKGROUND: Utilisation of emergency department (ED) for non-urgent problems, usually dealt with in first line health services (FLHS), has an impact both in terms of efficiency (ED care is more expensive than primary health care) and in terms of quality of care (due to ED overcrowding). This study describes the utilisation pattern of the ED at the Children's Hospital of Rabat (CHR) and assesses the appropriateness of ED utilisation. METHODS: During a whole week in September 1991, 24 h/24, information about every child admitted in the ED was collected by outside investigators, using a questionnaire. This questionnaire was divided into two sections. One section, filled out at admission of the child, consisted of the following items: time of arrival, health problem, health seeking pattern and identification of child (name, age, gender and address). The second section was filled out at the medical consultation and consisted primarily of a judgement about the relevance of ED utilisation (urgent/non-urgent condition, need for hospital-based equipment, subjective assessment of delay). RESULTS: During the week under study, 1,544 children were admitted at the ED: 904 at the medical ED and 640 at the surgical ED. At the medical ED, the proportion of urgent cases was 38%; among them, 65% needed hospital-based equipment and among the latter 72% arrived on time. It means that only 18% of the children utilised the ED in an appropriate way. At the surgical ED, the proportion of urgent cases was 56%; among them, 41% needed hospital-based equipment and among the latter 86% arrived on time. It means that only 20% of the children appropriately utilised the surgical ED. Appropriate utilisation is not associated with gender. The proportion of cases judged as urgent was associated neither to hour of admission--at least for the medical ED--nor to distance (less than 15 km). However, the proportion of urgent cases varied according to the day of the week. CONCLUSION: Results confirmed the opinion of the CHR staff: most children admitted to the ED had health problems that should have been cared for at FLHS. Rationalisation of ED utilisation will depend on the health system's ability to supply acceptable and accessible care at FLHS.

Adolescent↗

PubMed1999

[Why patients do not comply with reference decision made by general practitioners?].

SUBJECT: A health system's efficacy depends on the efficacy of its different components (first-level health services and hospitals). It also depends on the system's ability to ensure the continuity of care among the various levels of the system. Health care officials in Settat Province, Morocco, found continuity in this province to be unsatisfactory. Depending on the health centre involved, only 31 to 52% of patients referred from the first to the second level of care reached the hospital. METHODS: The study was conducted in two rural and two urban health centres (HCs) covering a total population of around 94,000. The methodology consisted of two steps. First we analysed retrospectively various determinants (age, gender, distance, time until appointment) that might influence the compliance of patients referred by the four health centres in 1994. Then we observed curative medical consultations conducted in each of these health centres over a three-day period; the 38 patients referred to the hospital over this period were interviewed and the organisation of the hospital used on was analysed. RESULTS: The results revealed low compliance: only 43% (782/1807) of the patients referred actually consulted the hospital's departments. The compliance rates varied from one HC to the other and were lower in rural than urban areas taken as a whole (34% (207/607) versus 48% (575/1200), respectively). The interviews revealed that patients did not trust the last-year medical students who staffed the emergency rooms. Another organisational problem in the hospital was identified: patients referred to the hospital to consult a specialist were not seen immediately but given appointments at later dates, and these waiting times influenced the final success of the referral process. Thus, if the patients were seen immediately, compliance increased from 48 to 77% in the case of the urban HCs and from 34 to 67% in the case of the rural HCs. CONCLUSION: The most important determinants of compliance were above all associated with the way health services were organized and the quality of communication between health professionals and patients.

Adolescent↗

PubMed1998

Effects of a refugee-assistance programme on host population in Guinea as measured by obstetric interventions.

BACKGROUND: Since 1990, 500000 people have fled from Liberia and Sierra Leone to Guinea, west Africa, where the government allowed them to settle freely, and provided medical assistance. We assessed whether the host population gained better access to hospital care during 1988-96. METHODS: In Guéckédou prefecture, we used data on major obstetric interventions performed in the district hospital between January, 1988, and August, 1996, and estimated the expected number of births to calculate the rate of major obstetric interventions for the host population. We calculated rates for 1988-90, 1991-93, and 1994-96 for three rural areas with different numbers of refugees. FINDINGS: Rates of major obstetric interventions for the host population increased from 0.03% (95% CI 0-0.09) to 1.06% (0.74-1.38) in the area with high numbers of refugees, from 0.34% (0.22-0.45) to 0.92% (0.74-1.11) in the area with medium numbers, and from 0.07% (0-0.17) to 0.27% (0.08-0.46) in the area with low numbers. The rate ratio over time was 4.35 (2.64-7.15), 1.70 (1.40-2.07), and 1.94 (0.97-3.87) for these areas, respectively. The rates of major obstetric interventions increased significantly more in the area with high numbers of refugees than in the other two areas. INTERPRETATION: In areas with high numbers of refugees, the refugee-assistance programme improved the health system and transport infrastructure. The presence of refugees also led to economic changes and a "refugee-induced demand". The non-directive refugee policy in Guinea made such changes possible and may be a cost-effective alternative to camps.

Adult↗

PubMed1998

Monitoring unmet obstetric need at district level in Morocco.

Unmet obstetric need was assessed in Taounate province (Morocco) during the year 1995 by monitoring rates of major obstetric intervention for absolute maternal indications. We report results in terms of spatial distribution of the failures of the health care system to provide women with essential emergency obstetric care. An estimated 135 women with life-threatening conditions did not benefit from the obstetric interventions they required. The paper documents the effects of the monitoring process on the way the provincial team changed their way of dealing with deliveries. Assessment of unmet obstetric need in Taounate province proved feasible and affordable without external budgetary inputs. It provided the team with information on the magnitude of a previously ignored problem. The results were so dramatic as to lead the team to look for causes and solutions. These were clearly not merely technical but systemic in nature.

Female↗

PubMed1998

Strategies for reducing maternal mortality in developing countries: what can we learn from the history of the industrialized West?

Ten years of Safe Motherhood Initiative notwithstanding, many developing countries still experience maternal mortality levels similar to those of industrialized countries in the early 20th century. This paper analyses the conditions under which the industrialized world has reduced maternal mortality over the last 100 years. Preconditions appear to have been early awareness of the magnitude of the problem, recognition that most maternal deaths are avoidable, and mobilization of professionals and the community. Still, there were considerable differences in the timing and speed of reduction of maternal mortality between countries, related to the way professionalization of delivery care was determined: firstly, by the willingness of the decision-makers to take up their responsibility; secondly, by making modern obstetrical care available to the population (particularly by encouragement or dissuasion of midwifery care); and thirdly, by the extent to which professionals were held accountable for addressing maternal health in an effective way. Reduction of maternal mortality in developing countries today is hindered by limited awareness of the magnitude and manageability of the problem, and ill-informed professionalization strategies focusing on antenatal care and training of traditional birth attendants. These strategies have by and large been ineffective and diverted attention from development of professional first-line midwifery and second-line hospital delivery care.

Developed Countries↗

PubMed1997

Hospitals in sub-Saharan Africa: why we need more of what does not work as it should.

This paper analyses the origins of today's crisis in the hospital sector in sub-Saharan Africa. Present trends in availability of hospital services are extrapolated to the future in order to provide a low-end estimate of the need for expansion of first referral level hospitals, This will not be possible without giving due priority to this sector, a commitment to considerable investments and reorientation of resources from tertiary to first referral level hospitals. It is to be feared that if this is not done, the backlog will increase, and, given the time lag before investments translate into operational services, there will be a major shortage of hospital services in sub-Saharan Africa within a decade.

Africa South of the Sahara↗

PubMed1996

[Estimation of need for obstetrical interventions in Morocco. An approach based on the spatial analysis of deficits].

One of the indicators of health system effectiveness with regard to maternal health is the maternal mortality ratio. Measuring this ratio in developing countries is, however, not an easy task since reliable information on mortality is rarely available. An alternative to the maternal mortality ratio measurement, as an indicator of effectiveness, is the assessment of the coverage of obstetrical intervention needs. The authors chose to restrict the notion of "needs" to the obstetrical interventions carried out in order to save a mother's life. Using data from a survey by the Ministry of Health of the Moroccan Kingdom on all the obstetrical interventions carried out in 1989, obstetrical intervention rates for "absolute maternal indications" are analysed according to the mother's origin, by province and urban/rural environment. The spatial analysis of these rates showed large variations in each of the environments (0 to 2.14 % of the expected births in urban areas and 0 to 1.25 % in rural areas) and a significative difference between the rural and urban distributions (median 0.80 % in urban areas versus 0.30 % in rural areas). Applying a reference rate of 1 %, deficits between the expected numbers of needed obstetrical interventions and the observed numbers were calculated for every province in both urban and rural areas. In the whole of Morocco, intervention rates are markedly below what is expected. The spatial analysis of the deficits helps to identify the provinces where the problem is the most prominent in terms of numbers of women whose intervention needs have to be covered. The authors discuss the validity of the reference rate and suggest several strategies to solve the problem. They conclude that the deficits map is a useful tool to decide on priorities for planning and monitoring of strategies to be implemented. The spatial analysis of obstetrical intervention deficits seems to be an instrument both cheaper and more relevant than a maternal mortality estimates survey.

Developing Countries↗

PubMed1996

Hands-on training in health district management.

Explore the source record for details and available documents.

Democratic Republic of the Congo↗

PubMed1995

The strategy of risk approach in antenatal care: evaluation of the referral compliance.

The main goal of antenatal care in developing countries is to identify women whose pregnancy or delivery is likely to raise problems and to refer them at the appropriate time to a hospital facility where the necessary medical equipment and expertise (vacuum extractors, cesarian sections, human skill, etc.) is available. This approach, which is known as the Risk Approach (RA) strategy, is expected to significantly reduce maternal morbidity and mortality. However, the RA will function properly only if the women identified at risk agree to give birth in a hospital on the one hand, and if they can indeed reach this hospital on the other hand. In this article the authors assess to what extent women with a risk of difficult labor (nulliparous or primiparous women under 150 cm, history of previous difficult delivery or stillbirth, women with transverse lie) agreed to give birth in a hospital. This descriptive survey, which covered 5060 pregnancies monitored in the Kasongo District, Maniema, in eastern Zaire, showed that the referral success rate in this socioeconomically very disadvantaged region was only 33%, despite some favorable conditions, such as a strong emphasis on community participation, a complementarity of health centers and hospital, and the absence of financial barriers within the health services system. Of the various hypotheses tested, the geographic accessibility of the hospital and the parturient's perception of the risk status were the two most important factors determining the compliance rate. A stratified analysis shows that the intensity of the parturient's perception has a different impact on compliance whether rural or urban situations are considered.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMedDate not supplied

Assessment of appropriate child care at district level: how useful are mortality rates?

Explore the source record for details and available documents.

Child↗

PubMedDate not supplied

[Between scientific management and research-action: the problem of overconsumption of drugs in Kasongo (Zaire)].

A Primary Health Care (PHC) system may be effective and efficient to the extent that essential drugs are available in health services and financially accessible to the population. In developing countries, besides the difficulties related to supplying health services with adequate amounts of drugs, the control of drug consumption is one of the frequent problems encountered by health authorities. Literature is relatively abundant in the field of rationalization of the diagnosis and drug prescription processes, and also in the field of drug financing mechanisms; publications are however rather scarce when topics related to corruption or drug misappropriation are concerned. The case study submitted hereafter reports a drug overconsumption problem in the health centres (HC) of the Kasongo district (Zaire). Despite the existence of direct control mechanisms as well as indirect ones (monitoring of drug consumption by HC), the problem has been identified belatedly. The district staff then used a step-by-step analysis of the HC drug consumption profiles; this analysis allowed to demonstrate that misappropriation would be the most plausible hypothesis. In order to solve the misappropriation problem-the consequences of which jeopardized the functioning of the very health system-the district staff chose to involve the nurses, in charge of the HC, in the entire problem-solving process. This participative approach, involving different actors as partners, allowed to deepen the situation analysis and to elaborate solutions congruent with PHC principles and acceptable to all concerned.

Democratic Republic of the Congo↗