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PubMed1998

Healthcare systems process reengineering for developing countries: a report to IMIA Working Group 9.

To discover what kinds of health informatics the developing countries need, we look first to the underlying social structures that informatics is to support. Developing countries face severe problems in their goal of assuring access to quality healthcare to their citizens. Nor is it comforting to look to the example of the developed countries, themselves uncomfortable with the tremendous commitment of resources that they use. It seems clear that if developing countries are to succeed their systems for assuring health will need to achieve radical improvements over those currently employed by the developed countries. They need to build systems that are directed to the heart of the problems; they need to make the best use of their existing human and economic resources; and they need to do this while respecting the human potential and aspirations of their people. Any such system will need to be built around planning, organizing and measuring the long-term, rather than episodic, health of citizens. In particular, health interventions need to be moved upstream where they are more effective and less expensive. The job of health informatics is to provide the fundamental enabling infrastructure that would allow individuals to cooperate in the fluid, effective ways required. We describe some of the requisites for such a system. Certainly, its construction will depend on the use of an open, standards-based distributed object software architecture.

Delivery of Health Care↗

PubMed2005

Surgery in developing countries: essential training in residency.

HYPOTHESIS: A surgical elective in a developing country setting is an essential new component in academic residency training. DESIGN: A survey of residents and faculty within the Department of Surgery at the University of California-San Francisco, and a collaborative program piloted between the Department of Surgery at the University of California-San Francisco and Makerere University in Kampala, Uganda, including a 6-week clinical elective. SETTING: Mulago and Nsambya hospitals in Kampala, Uganda. PARTICIPANTS: Two residents and three faculty advisors at the University of California-San Francisco. INTERVENTION: Development of a 6-week pilot clinical surgical elective. MAIN OUTCOME MEASURES: Assessment of the level of interest in international health in an academic surgery program; pathology and case variety, diagnostic methods, and surgical and anesthetic resources and techniques in a pilot developing country. RESULTS: Forty percent of residents enter residency with prior international health experience whereas 90% express interest in a developing country elective. Twenty-five percent of faculty participate in voluntary international surgical service and research projects. As a result of the survey and the level of interest in our program, two visits to Uganda were made and a residency elective rotation was successfully created. This resulted in exposure of residents to the educational benefits of learning in a resource-constrained setting: a broader scope of surgical conditions and pathology, greater reliance on history-taking and physical examination skills in a low-technology environment, and sociocultural aspects of care provision. Greater questions about global health equity, access to information, and the role of surgery in public health are raised along with potential challenges in international collaboration. CONCLUSIONS: A developing country surgical experience complements the academic mission of service, training, and research, and should be an essential component of surgical training programs. There is interest among residents and faculty in such a program as well as a need for greater commitment to north-south collaborations among academic surgical institutions and societies, as has been successfully implemented abroad. More generally, surgery is an integral part of public health and health systems development worldwide.

California↗

PubMed2000

A comparison of the extent and impacts of sewage contamination on urban groundwater in developed and developing countries.

In much of the world urban groundwater is an important resource for domestic and industrial use. In many developing countries, groundwater taken directly (untreated) from individual springs and wells is the only option available to communities where comprehensive, reliable reticulated supply systems are absent. A common feature of urban groundwater in both developing and developed countries is contamination by sewage. Current and recent research is presented that shows sewer leakage impacts groundwater in developed countries whilst on-site sanitation contaminates groundwater in developing countries. In the latter case, the competing demands of sanitation and groundwater protection must be addressed. Limitations on the usefulness of accepted standard sewage indicator species in groundwater are also highlighted. As sewage contamination of groundwater is usually addressed only if an actual health risk is posed, it is vital both to developed and developing countries to understand the movement of actual pathogens in groundwater in the context of groundwater management. Further research is required on microbial survival and health risks posed by sewage contamination.

Cross-Cultural Comparison↗

PubMed1999

Modelling the incidence of congenital rubella syndrome in developing countries.

BACKGROUND: As of 1997, less than one-third of developing countries included rubella vaccine in their national immunization programme. In countries that have achieved high coverage of measles vaccine, an ideal opportunity exists to include control of rubella and congenital rubella syndrome (CRS) in enhanced measles control activities. Data on the burden of congenital rubella syndrome are important to guide rubella vaccination policies. METHODS: We reviewed the literature to identify studies of rubella antibody prevalence in developing countries that were conducted on populations with no major selection bias, prior to wide-scale rubella vaccination in the country. We used a simple catalytic model to describe the age-specific prevalence of susceptibility to rubella virus infection in given populations. Estimates of the incidence of infection among pregnant women were calculated using expressions for the average prevalence of susceptibility to infection and the incidence of infection during gestation. To estimate the number of cases of CRS, we assumed an overall risk of 65% after infection in the first 16 weeks of pregnancy and zero risk thereafter. These estimates were derived for each country for which data were available, then for each World Health Organization region, excluding Europe. RESULTS: The estimated mean incidence of CRS per 100,000 live births was lowest in the Eastern Mediterranean region (77.4, range 0-212) and highest in the Americas (175, range 0-598). The mean of the estimates of the total number of cases of CRS in developing countries in 1996 was approximately 110,000. The range was, however, very wide, from as few as 14,000 to as many as 308,000 cases. CONCLUSIONS: Congenital rubella syndrome is an under-recognized public health problem in many developing countries. There is an urgent need for collection of appropriate data to estimate the cost-effectiveness of a potential global rubella control programme.

Adolescent↗

PubMed1994

The fight against tobacco in developing countries.

The battle to reduce the tobacco epidemic is not being won; the epidemic is merely being transferred from rich to poor countries. Tobacco-related mortality will rise from the present annual global toll of 3 million to over 10 million by the year 2025. Currently, most of these deaths are in developed countries but 7 out of the 10 million deaths will occur in developing countries by 2025. Developing countries cannot afford this increase, either in terms of human health or in economic costs, such as medical and health care costs, costs of lost productivity, costs of fires or costs of the misuse of land used to grow tobacco. As many of the tobacco-related illnesses, such as lung cancer or emphysema, are incurable even with expensive technology, the key to tobacco control lies in prevention. The essential elements of a national tobacco control policy are the same for all countries throughout the world--the only differences lie in fine tuning to a country's current situation. While indigenous production and consumption of tobacco remain a problem, of particular concern is the penetration of developing countries by the transnational tobacco companies, with aggressive promotional campaigns and the use of political and commercial pressures to open up markets and to promote foreign cigarettes. This includes specific targeting of women, few of whom currently smoke in developing countries. Also, tobacco advertising revenue prevents the media from reporting on the hazards of tobacco, a particularly serious problem in developing countries where awareness of the harmfulness of tobacco is low.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗

PubMed2000

Epilepsy surgery in developing countries.

Epilepsy surgery (ES) is a well-accepted treatment for medically intractable epilepsy patients in developed countries, but it is highly technology dependent. Such technology is not usually available in developing countries. For presurgical evaluation, magnetic resonance imaging (MRI) and electroencephalogram recording while videotaping the patient have been important. High technology equipment will, in conjunction with MRI, identify approximately 70% of ES candidates. Introducing ES into developing countries will require determining the candidates that are appropriate for the existing medical infrastructure. This article reviews ES and its possible introduction into conditions existing in developing countries. The authors address (a) the types of patients to be considered for resective ES (some patients require a fairly standard series of noninvasive studies: others will require extensive invasive studies), (b) ways to determine which patients might be appropriate for the existing situation (unilateral mesial temporal lobe epilepsy detected with MRI, epilepsy with a circumscribed MRI lesion, hemispheric lesions, circumscribed MRI detected neuronal migration, and development disorders), (c) surgical procedures (local resection, functional hemispherectomy, multiple subpial transections, corpus callosotomy, and implantation of a vagal nerve stimulator), (d) special considerations for introducing ES into developing countries (medical infrastructure, technology, seizure monitoring systems, selective intracarotid/carotid Amytal testing, and surgical equipment), and (e) the limitations, realistic expectations, personnel requirements, and educational function for selected professionals. Delivery of the technology and expertise to perform ES in developing regions of the world is a realizable project, but it would be limited by available technology and existing medical infrastructure. It should be possible in most areas to train local personnel and thereby leave a lasting legacy.

Cerebral Cortex↗

PubMed2006

Oral lesions in HIV infection in developing countries: an overview.

HIV infection is a major global health problem affecting developing and developed countries alike. Oral lesions that are associated with this disease are important, since they affect the quality of life of the patient and are useful markers of disease progression and immunosuppression. Oral lesions in HIV infection have been well-documented in developed countries, but there are fewer reports on oral lesions from developing countries. Oral candidiasis is the most common opportunistic infection seen in all continents. Kaposi's sarcoma has been reported only from Africa and Latin America, while histoplasmosis and penicilliosis were reported in patients with advanced disease from Thailand. HIV-associated salivary gland disease has a high prevalence in Africa and Latin America, especially in the pediatric group. It is clear that there are considerable regional variations in the oral manifestations of HIV infection, depending both on the populations studied and on the clinical expertise available, among other factors. Well-designed and -documented studies are necessary for the correct assessment of the nature and magnitude of the problem in developing countries, if oral health measures are to be effectively formulated for the HIV-infected.

AIDS-Related Opportunistic Infections↗

PubMed1976

Medical treatment of sexually transmitted disease in developing countries I: Gonorrhoea.

The statistics relating to the incidence of sexually transmitted diseases in many developing countries are not available and where there are, they are unreliable. Nevertheless, the impression of many physicians is that they constitute serious public health problems as they are endemic in some developing countries. The facilities for diagnosis and treatment of the diseases have been briefly discussed. The merits and the demerits of various antimicrobial agents have been outlined with the causes of failure of treatment in the developing countries. The economic importance of the "traitment minute" in the tropical environment has been stressed because of its economic advantage in terms of time spent in overcrowded hospitals. The resultant effect of the widescale misuse of antibiotics in developing countries has been suggested as a cause of the increasing resistant strains encountered. A plea is made for stricter control of the antimicrobial agents in developing countries.

Ampicillin↗

PubMed2003

Blood cholesterol level and prevalence of hypercholesterolaemia in developing countries: a review of population-based studies carried out from 1979 to 2002.

BACKGROUND: While the age-specific rates of cardiovascular diseases (CVD) are declining in many developed countries, the epidemic is accelerating in most developing countries. Elevated serum total cholesterol (TC) is one of the major risk factors for atherosclerotic CVD. This review was carried out to describe the current situation in mean TC and in the prevalence of hypercholesterolaemia in developing countries. DESIGN AND METHODS: A search for papers published in medical journals from 1990 to 2002 was performed using the MEDLINE database. A total of 37 articles were selected according to previously defined criteria containing information on mean blood total cholesterol and/or hypercholesterolaemia from 38 developing countries. RESULTS: Hypercholesterolaemia is a public health problem in most of the developing countries reviewed. A positive association between the population mean TC and the GNP per capita was evidenced. CONCLUSIONS: Differences in methodology between national surveys make international comparisons difficult. Nevertheless, low-cost dietary interventions and the development of primary prevention strategies are needed to reduce the already existing public health problem of elevated TC in developing countries.

Cholesterol↗

PubMed1991

Use of intraocular lenses in cataract surgery in developing countries: memorandum from a WHO meeting.

Visual loss or disability from cataract represents a massive public health and socioeconomic problem in most developing countries. At present, some 13.5 million cases require treatment and this number will increase, as most countries in the Third World are unable to cope with both the backlog and new cases. Cataract extraction with intraocular lens (IOL) implantation is now the established and preferred method in industrialized countries. The introduction of IOLs in developing countries, however, depends on their having adequately trained manpower and facilities (equipment and supplies, including IOLs) for surgery. This will inevitably increase the cost per operated case which, despite the scarce resources for cataract surgery in many developing countries, may be justified by the improved restoration of the patient's vision. Experience has led to the following generic designs for IOLs: the one-piece or three-piece C-loop polymethylmethacrylate (PMMA) posterior chamber lens, which is the current favourite; and, the flexible or rigid one-piece all-PMMA anterior chamber lens, which is a valid alternative in many situations. Further scientific evaluation of the use of these lenses in a wide variety of settings in developing countries is required. Operations research is also needed in order better to define and standardize the various steps and procedures in the surgical and post-operative management of IOL implantation in Third World settings. Meanwhile, the following should be available to ensure safe and good quality cataract surgery using IOLs in developing countries: properly trained surgeons; the needed facilities and equipment with regular supplies; a good quality lens of appropriate design; and the necessary means for careful follow-up of operated patients.

Cataract Extraction↗

PubMed2006

Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries.

BACKGROUND: Both religious practices and male circumcision (MC) have been associated with HIV and other sexually-transmitted infectious diseases. Most studies have been limited in size and have not adequately controlled for religion, so these relationships remain unclear. METHODS: We evaluated relationships between MC prevalence, Muslim and Christian religion, and 7 infectious diseases using country-specific data among 118 developing countries. We used multivariate linear regression to describe associations between MC and cervical cancer incidence, and between MC and HIV prevalence among countries with primarily sexual HIV transmission. RESULTS: Fifty-three, 14, and 51 developing countries had a high (>80%), intermediate (20-80%), and low (<20%) MC prevalence, respectively. In univariate analyses, MC was associated with lower HIV prevalence and lower cervical cancer incidence, but not with HSV-2, syphilis, nor, as expected, with Hepatitis C, tuberculosis, or malaria. In multivariate analysis after stratifying the countries by religious groups, each categorical increase of MC prevalence was associated with a 3.65/100,000 women (95% CI 0.54-6.76, p = 0.02) decrease in annual cervical cancer incidence, and a 1.84-fold (95% CI 1.36-2.48, p < 0.001) decrease in the adult HIV prevalence among sub-Saharan African countries. In separate multivariate analyses among non-sub-Saharan African countries controlling for religion, higher MC prevalence was associated with a 8.94-fold (95% CI 4.30-18.60) decrease in the adult HIV prevalence among countries with primarily heterosexual HIV transmission, but not, as expected, among countries with primarily homosexual or injection drug use HIV transmission (p = 0.35). CONCLUSION: Male circumcision was significantly associated with lower cervical cancer incidence and lower HIV prevalence in sub-Saharan Africa, independent of Muslim and Christian religion. As predicted, male circumcision was also strongly associated with lower HIV prevalence among countries with primarily heterosexual HIV transmission, but not among countries with primarily homosexual or injection drug use HIV transmission. These findings strengthen the reported biological link between MC and some sexually transmitted infectious diseases, including HIV and cervical cancer.

Africa South of the Sahara↗

PubMed1990

Forecasting chronic disease risks in developing countries.

Declining fertility and infant mortality has caused the population in many developing countries to age. Population ageing can produce a rapid shift in the predominant public health problems from infant mortality and infectious diseases to chronic disease mortality at later ages. Designing public health strategies to deal with the health consequences of population ageing in developing countries is difficult both because of a remaining burden of infectious diseases and because of changes in life style associated with economic development that may raise chronic disease risks. Because there are few longitudinal studies of chronic disease risks in developing countries, we investigate the use of a planning and forecasting model, which combines data from multiple sources, in six developing countries.

Adolescent↗

PubMed2006

Achieving the global goals on HIV among young people most at risk in developing countries: young sex workers, injecting drug users and men who have sex with men.

OBJECTIVE: To review evaluations of interventions in developing countries targeting three groups most at risk of becoming infected with HIV: young sex workers, young injecting drug users and young men who have sex with men. METHODS: A systematic literature review was undertaken to identify programmes in developing countries targeting young people in the three selected groups most at risk from HIV. We also identified programmes directed at young people in developed countries as well as programmes in developing countries that targeted these three population groups but that did not differentiate between young people and adults. FINDINGS: Young people 10 to 24 years of age represent a large proportion of the population most at risk of becoming infected with HIV in developing countries. Despite this fact, well documented evaluations of interventions that target these groups are scarce. However, there is evidence of effectiveness for programmes that are facility-based and use outreach to provide information and services to at-risk young people. CONCLUSION: There is growing evidence from developing countries of successful interventions that target groups most at risk from HIV, and these programmes should be widely implemented provided that they are carefully planned and monitored and have a strong evaluation component. However, there is an urgent need to disaggregate data by age in order to determine how effective these programmes are in reaching young people and to better understand the specific needs of at-risk young people as opposed to older age groups.

Adolescent↗

PubMed1990

Vaccines in health strategies for developing countries--priorities and technology transfer.

Millions of people in developing countries are still at risk of dying of infectious diseases such as hepatitis B, typhoid, tuberculosis and cholera despite the existence of relevant vaccines. For economical reasons commercial firms are not keen to invest in new or improved vaccines meant for the Third World market. Yet some vaccines could be made cheaply if there was more effort in transfer of knowledge and technology between scientists of the technically developed countries and the Third World. National governments and research institutions should accept a special responsibility to mobilize available manpower and technical resources to provide the right vaccines at the right cost to those who need them the most. Without rapid progress in this field, developing countries will lack some of the most cost effective tools in their strategies for preventing disease, disability and death.

Developing Countries↗

PubMed2003

Use of a major medical center clinical laboratory as a reference laboratory for a developing country: ordering patterns help set laboratory priorities.

BACKGROUND: The test menus for developed and developing countries may differ, depending on many factors, including the expected volume of testing, disease frequency and therapies available, clinical impact of the test, technical skill and equipment needed, cost, the patient population served, and whether alternative testing sites are available, and some of them may not be exactly known. We assessed test priorities in a developing country by making a broad range of tests available and then assessing which tests were actually used by the physicians in the country for the care of their patients. METHODS: The Barnes-Jewish Hospital laboratory and Washington University Medical Center provided patients in the developing country of Eritrea access to the same tests as patients in St. Louis for all analytes that are stable at 4 degrees C, the lowest temperature that could be used for shipping. RESULTS: The use of the St. Louis laboratories increased steadily from 1998 to 2001. More than one-half of the physicians in Eritrea used the reference laboratories, with requests for thyroid function and female fertility representing 48-71% of the test requests over the 4 years evaluated. The high degree of utilization for these test batteries was not predicted. Testing for thyroid function, female fertility, and lipid panels are now performed, or soon will be performed, in Eritrea based on the experience of the reference laboratory system. The reference laboratory system is continuing so that the test priorities of the country can be evaluated on an ongoing basis and specialized tests can be made available at a low cost. CONCLUSION: The experiences of a reference laboratory for a developing country can help to identify unanticipated priorities for medical testing within the country.

Clinical Laboratory Techniques↗

PubMed1981

Training of psychiatrists for developing countries.

There are significant differences in approaches to the training of psychiatrists in developed and developing countries. In the latter, with acute shortages of manpower in psychiatry and gross deficiencies in psychiatric services, there is a need for training programs to emphasise the practical needs of the country. The aim should be to produce a well-rounded generalist who is capable of coping with most psychiatric problems with little access to a clinical psychologist or social worker, both of whom are usually not readily available in developing countries. The trainee should have a good grounding in the briefer psychotherapies and behaviour modification. There is a need to pool resources in developing countries to initiate local training programs. Cooperation between developed and developing countries can also play a useful role in the starting of regional training programs to benefit several countries.

Behavior Therapy↗

PubMed2005

Suicide in developing countries (3): prevention efforts.

Until now, suicide prevention efforts have been limited in developing countries, although there are pockets of excellent achievement. Various universal, selective, and indicated interventions have been implemented, many of which target a different pattern of risk factors to those in developed countries. In the absence of sufficient mental health services, developing countries rely heavily on nongovernment organizations (NGOs) to provide crisis interventions for suicidal individuals, as well as proactive interventions aimed at raising community awareness and building resilience. Often these NGOs work within a social and public health framework, collaborating with others to provide nested suicide prevention programs that are responsive to local community needs. There is a clear need to develop appropriate, relevant and effective national suicide prevention plans in developing countries, since, to date, only Sri Lanka has done so. These plans should focus on a range of priority areas, specify the actions necessary to achieve positive change in these priority areas, consider the range of collaborators required to implement these actions, and structure their efforts at national, regional, and local levels. The plans should also promote the collection of accurate data on completed and attempted suicide, and should foster evaluation efforts.

Crisis Intervention↗

PubMed1981

Strategies for water supply systems in developing countries.

Among the major water supply problems in developing countries are the lack of qualified manpower, inadequate management, and limited financial resources. Trained personnel is not only deficient in many of the water agencies, but also in ministries, health agencies, community organizations and labour categories of all kinds. Operation and maintenance, quality control and revenue collection leave much to be desired. The scarce resources are barely or not at all sufficient to scope with the day to day problems, let alone with investments for the future. These situations differ considerably from region to region. Several countries may have manpower available but lack finance. Others may have ample funds, but have a shortage of trained people. Many have neither of them. Management problems occur almost everywhere. Each of the countries has its own options and constraints for future developments. In many developing countries there is also a serious scarcity of water resources. In these countries the introduction of water reuse practices would be an obvious option. The policies and the choice of technologies however, should be seen in the light of these countries overriding problems.

Developing Countries↗