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PubMed2001

[Access of developing countries to essential drugs: a process of equity].

In the context of the fight against poverty, the access of developing countries to essential drugs mobilizes the international community. It leads to envisage new and intricates politics. If donations or tiered prices are studied, the manufacturing of generics and even of patented drugs through voluntary or compulsory licensing is evoked. At a longer terms, it's the setting of health national politics and industrialisation which are concerned. These new orientations are not without consequence on the global drug market.

Developing Countries↗

PubMed2006

Guidelines for conducting rapid participatory appraisals of community health needs in developing countries: experience from Tulikup, Bali.

The use of rapid participatory appraisal (RPA) methodology to assess community health needs in developing countries is widely supported. Despite this, there are few recently published practical guidelines or recommendations advising researchers on how best to plan, implement and communicate such an activity. Having recently conducted a successful RPA of community health and social needs in the traditional rural village of Tulikup, Bali, the authors discuss lessons to be learned and suggest practical guidelines for others wishing to conduct similar community focused RPAs.

Community Health Services↗

PubMed2004

Health policy and systems research agendas in developing countries.

BACKGROUND: Health policy and systems research (HPSR) is an international public good with potential to orient investments and performance at national level. Identifying research trends and priorities at international level is therefore important. This paper offers a conceptual framework and defines the HPSR portfolio as a set of research projects under implementation. The research portfolio is influenced by factors external to the research system as well as internal to it. These last include the capacity of research institutions, the momentum of research programs, funding opportunities and the influence of stakeholder priorities and public opinion. These dimensions can vary in their degree of coordination, leading to a complementary or a fragmented research portfolio. OBJECTIVE: The main objective is to identify the themes currently being pursued in the research portfolio and agendas within developing countries and to quantify their frequency in an effort to identify current research topics and their underlying influences. METHODS: HPSR topics being pursued by developing country producer institutions and their perceived priorities were identified through a survey between 2000 and 2002. The response to a call for letters of intent issued by the Alliance in 2000 for a broad range of topics was also analyzed. The institutions that were the universe of this study consisted of the 176 institutional partners of the Alliance for Health Policy and Systems Research producing research in low and middle income countries outside Europe. HPSR topics as well as the beneficiaries or issues and the health problems addressed were content analyzed. Topics were classified into 19 categories and their frequency analyzed across groups of countries with similar per capita income. Agendas were identified by analyzing the source of funding and of project initiation for projects under implementation. RESULTS: The highest ranking topic at the aggregate level is "Sector analysis", followed by "Disease burden" and "Management and organization". Categories at the bottom of this ranking are "Equity", "Policy process", "Economic policy and health" and "Information systems". "Disease burden" is more often funded than other topics for which there is more demand or perceived priority. Analysis suggests few although important differences across priorities, demand for funding and actual project funding. The donors' agenda coincides most with the ranking of research topics overall.Ranking across country income groups shows important differences. Topics that gain prominence in low income countries are "Disease burden" and "Accessibility". In lower middle income countries "Insurance" gains prominence. In upper middle income countries "Decentralization/local health systems", "Equity" and "Policy process" are more prominent. "Program evaluation" is the most consistently ranked topic across income regions, showing a neutral influence by donors, governments or researchers. CONCLUSIONS: The framework proposed offers a basis to identify and contrast research needs, projects and products at the international level and to identify the actor agendas and their influence. Research gaps are suggested when comparing topic ranking against the challenges to health system strengthening and scaling up of disease control programs. Differences across per capita income groups suggests the need for differentiated priority setting mechanisms guiding international support. Data suggests that stakeholders have different agendas, and that donors predominate in determining the research portfolio. High-level consensus building at the national and international levels is necessary to ensure that the diverse agendas play a complementary role in support of health system objectives.The Ministerial Summit for Health Research to be held in Mexico in November 2004 should be an opportunity to analyze further data and to commit funding for priorities identified through sharing and discussion of agendas.

Journal Article↗

PubMed1999

The economics of optimal health and productivity in smallholder livestock systems in developing countries.

Livestock kept or produced in smallholder farming systems are an important component of the agricultural economy in the developing world. The role of livestock on smallholder farms varies widely, providing draught power for crop production or as a production activity for subsistence needs or market sale under systems ranging from extensive pastoralist to intensive, peri-urban feeder and dairy systems. A set of unique conditions and features characterise smallholder systems, and these need to be appreciated when assessing the strategies that have evolved for managing animal health in smallholder systems, and evaluating opportunities for improving disease control strategies. To provide a framework for discussing animal health issues and analytical methodogies, a typology of smallholder livestock and crop/livestock systems is developed. The typology considers livestock systems both in terms of the degree of intensification, as measured by market orientation and intensity of factor use, and in terms of importance within the household economy, as measured by contribution to household income. A number of characteristics are identified that distinguish smallholder systems from the commercialised systems of developed countries, including the multiple functions livestock serve, the integrated nature of livestock activities, multiple objectives of producers and lower capacity to bear risk at the household level, as well as poor infrastructure, markets, and access to information at the community level. Three representative smallholder livestock systems from Africa are described in detail, highlighting the relevant characteristics and the implications for analysing disease control strategies. Smallholder dairy systems in Kenya demonstrate the role of individual producer decision-making for animal health management in intensive, market-oriented systems, placing emphasis on farm-level risk and production management aspects of disease control. In extensive pastoralist systems where epidemic disease are still important and infrastructure is poor, disease control primarily involves managing communal natural resources, requiring a different analytical approach. Finally, in crop farming systems using draught cattle, the livestock activity is an integrated component of crop production and this must be reflected in the approach used to evaluate draught animal health management. Continued development of analytical approaches and decision-support tools for disease control strategies adapted to the special characteristics of these systems will be needed as smallholder systems continue to intensify in areas with good market access, and those in marginal areas face increasing pressures to optimally manage the natural resource base.

Africa↗

PubMed1997

Changing indications for penetrating keratoplasty: a newly developed country's experience.

PURPOSE: To study the changing indications for penetrating keratoplasty in Singapore and compare local indications with developed countries with established corneal graft programs. METHODS: A descriptive study of all penetrating keratoplasty cases performed in the Singapore National Eye Center over a 5 year period, from 1 January 1991 to 31 December 1995 using records of the Singapore Eye Bank registry. RESULTS: A total of 327 penetrating keratoplasties were performed. Bullous keratopathy was the indication in more than a quarter of all cases (26.3%). Aphakic bullous keratopathy (11.6%) and pseudophakic bullous keratopathy (11.3%) accounted for the majority of the bullous keratopathy cases. The other leading indications were regrafts (11.9%), corneal dystrophies (10.4%), traumatic scarring (10.1%) and keratoconus (9.8%). A higher proportion of aphakic and pseudophakic bullous keratopathy as well as regrafts was noted in this series compared to a previous report on corneal transplantation in the 1980s. A rising indication rate of pseudophakic bullous keratopathy, in conjunction with a declining indication rate of herpetic keratitis was observed over the 5 year study period. CONCLUSIONS: The indications for penetrating keratoplasty in Singapore appear to follow the trend seen in developed Western countries over the past few decades.

Adolescent↗

PubMed1988

Transfer of medical technology from a developed to a developing country.

Medical care is increasingly dependent on technology, but what are the problems involved in the transfer of technology from a developed to a developing country? What are the administrative, personnel and engineering problems? We address these questions in the context of our experience of transferring the medical technology and knowledge necessary for the development of nuclear medicine facilities in Kuwait.

Biomedical Engineering↗

PubMed1989

The assessment of preventable infant and child deaths in developing countries: some applications of a new index.

This article briefly reviews epidemiological and demographic measures used to assess preventable deaths in developing country situations. Problems with the use of the infant mortality rate (IMR) as a health-policy indicator are illustrated. The Matlab experience of rural Bangladesh is used to develop a new index for preventable infant and child deaths. This index, based on a statistical transformation of usual demographic measures, links mortality levels and cause-of-death structure. The use of this index is illustrated with applications to Asia and Africa. It is claimed that the index exhibits more clearly the difficulty involved in the control of particular causes of death, thus providing important information for health policy makers.

Child↗

PubMed2003

Methods for studying private sector supply of public health products in developing countries: a conceptual framework and review.

The private sector is an important supplier of public health products (PHPs) in developing countries. Although there are concerns about the quality and affordability of these products, private providers also offer possibilities for expanding access to key commodities. This paper proposes a conceptual framework for understanding the public health implications of private sales of PHPs. It reviews methods for studying these sales, together with their advantages and shortcomings. Ten methods are identified which can be used for studying the behaviour of providers and consumers. The effects of seasonal variation are discussed, together with the challenges of creating a sampling frame and studying illicit behaviour. We conclude that relatively little is known about the sales of PHPs, that more is known about contraceptives and drugs than about the newer products, and that the demand side of the market has been studied in greater depth than the behaviour of suppliers. The existing toolbox is biased towards formal providers, and thus, probably towards understanding the provision of PHPs to those who are better off. Methods for studying the supply of PHPs in outlets used by poor people is a priority area for further methodological development.

Commerce↗

PubMed2003

Paediatric utilization of a general emergency department in a developing country.

AIM: Knowledge of the spectrum and frequencies of pediatric emergencies presenting to an emergency department (ED) of individual developing countries is vital in optimizing the quality of care delivered locally. METHODS: A prospective 6 wk review of all pediatric (< 18 y) attendees to an urban ED was done, with patient age, presenting complaints, diagnoses, time of arrival and disposition recorded. RESULTS: Complete data were available on 1172 patients, with an age range of 4 d to 18 y (mean +/- SD 6.9 +/- 5.6 y); 43% were aged < or = 4 y. The main presenting complaints were injuries (26.9%), fever (24%) and breathing difficulties (16.6%). The most common diagnosis was minor trauma (24.2%), with soft-tissue injuries predominating (80.6%). The other diagnoses were asthma (12.6%), upper respiratory infections (12.1%), other infections (12.1%) and gastroenteritis (11.8%). Equal proportions of patients were seen throughout the day. 25% of patients were admitted. Young age (< 1 y); presence of past medical history, general practitioner referrals, diagnosis of bronchiolitis and pneumonia were significantly associated with risk of admission. CONCLUSION: A wide spectrum of paediatric illnesses was seen in the ED, with an overrepresentation of young children. This supports the decision to have either a separate pediatric ED or paediatric residents on the staff. The training curricula should emphasize the management of pediatric trauma, infections and asthma. Alternatively, developing guidelines for the five most common presenting complaints would account for 82% of all attendees and could be directed towards all staff on the ED.

Adolescent↗

PubMed2004

Combating tropical infectious diseases: report of the Disease Control Priorities in Developing Countries Project.

Infectious diseases are responsible for >25% of the global disease toll. The new Disease Control Priorities in Developing Countries Project (DCPP) aims to decrease the burden of these diseases by producing science-based analyses from demographic, epidemiologic, disease intervention, and economic evidence for the purpose of defining disease priorities and implementing control measures. The DCPP recently reviewed selected tropical infectious diseases, examined successful control experiences, and defined unsettled patient treatment, prevention, and research issues. Disease elimination programs against American trypanosomiasis (Chagas disease), onchocerciasis, lymphatic filariasis, leprosy, trachoma, and measles are succeeding. Dengue, leishmaniasis, African trypanosomiasis, malaria, diarrheal diseases, helminthic infections, and tuberculosis have reemerged because of inadequate interventions and control strategies and the breakdown of health delivery systems. Application of technologies must be cost-effective and intensified research is essential if these and other scourges are to be controlled or eliminated in the 21st century.

Biomedical Research↗

PubMed2004

Reframing the HIV/AIDS debate in developing countries I: setting the scene.

In 2001, it was estimated that 4.7 million South Africans were living with HIV/AIDS. Prevalence figures have risen steadily over the past 10 years in most African countries, and in only a few, like Uganda, does the epidemic show signs of waning. In Africa, the status of the obese has risen enormously. If you're fat, you don't have AIDS. The epidemic is fuelled by many factors. These include: a lack of basic education about HIV risk; migrant labour disrupting family stability; polygamous marriages; patriarchal practices; and a lack of basic human rights, including being able to refuse intercourse, for women. Health care systems struggle and fail to cope with overwhelming demands, and the scale of the human loss risks dehumanising carers and health workers. Doctors evolve coping strategies, as do health systems and governments. Aid from the Western world has, until recently, been tokenistic in scale. HIV/AIDS in Africa is substantially a result of the socioeconomic and political realities of the past and present, and is related to the continued exploitation of developing countries by developed nations. This article was the introductory paper in the 'HIV/AIDS in the Developing World workshop' of the 2003 WONCA World Rural Health Congress, Santiago de Compostela, Spain. The concluding 'Santiago de Compostela Statement on HIV/AIDS' was adopted at the congress, and is offered here as a suggested way forward.

Journal Article↗

PubMed2001

Acidification in developing countries: ecosystem sensitivity and the critical load approach on a global scale.

Acidification represents a growing threat to certain developing country ecosystems in tropical and subtropical climates. A methodology investigating the extent of acidification risks from sulfur emissions on a global scale is presented. Atmospheric transfer models have been used to calculate transfer and deposition of sulfur (using emissions for 1990 and a projection for 2050) and alkaline soil dust. A method to derive the relative sensitivity of terrestrial ecosystems is explained and preliminary critical load values are assigned. A range of values for critical loads and base cation deposition have been used to investigate uncertainty in maps depicting the excess of deposition above critical loads. These show an increasing risk of acidification in 2050 in extended regions of southern and eastern Asia, as well as parts of southern Africa, in comparison to 1990. Certain areas, especially in Asia, are shown at risk even when high values of critical load and base cation deposition are used.

Acids↗

PubMed2002

Ocular manifestations of congenital rubella syndrome in a developing country.

PURPOSE: To describe the ocular manifestations of congenital rubella syndrome (CRS), a common cause of congenital cataracts in developing countries. METHODS: Retrospective analysis of case records of 46 sero-positive infants under 12 months of age who presented at Aravind Eye Hospital, Madurai between July 1993 and February 2001. The ocular and systemic examination details were recorded. RESULTS: Both eyes were affected in 41 (89%) patients. Cataract was present in 81 (93.1%) eyes; most of them were nuclear cataract (79, 97.5%). Other common ocular presentations included microphthalmos in 74 (85.1%) eyes, iris abnormalities in 51 (58.6%) eyes, and pigmentary retinopathy in 33 (37.9%) eyes. Cataract, microphthalmos and iris hypoplasia was a common combination present in 49 (56.3%) eyes. Systemic manifestations included cardiac anomalies in 23 (50%) and neurological anomalies in 16 (34%) children. Multi-system involvement was present in 32 (70%) children. Low birth weight (below 2 kg) was seen in 30% infants. CONCLUSION: CRS may present with a wide spectrum of ocular and systemic findings and requires a high index of suspicion for diagnosis. Any sick infant with unilateral or bilateral congenital cataract should be investigated thoroughly for CRS.

Abnormalities, Multiple↗

PubMed1990

Health education interventions in developing countries: a methodological review of published articles.

Some 67 journal articles that described and evaluated health education programmes in developing countries were read by two independent reviewers who examined the methodology used in the studies. Of the articles 47% provided a sufficiently detailed description of the educational intervention to allow replication and 40% described the educational level of the intended audience. Only 21% were controlled studies employing sample sizes greater than 60 individuals or two clusters, although six studies used randomized or quasi-randomized designs. Of the studies 33% looked at changes in health status while another 33% used observable changes in health behaviour as an endpoint. There was good agreement between the reviewers on whether these characteristics were present. Only three of the articles contained all four methodological attributes described above. The results of these articles suggests that successful health education depends on using a few messages, of proven benefit, repeatedly, and in many forums. It is important to improve the methodological quality of health education research. This can be done by using controlled, preferably randomized, designs, ensuring adequate sample sizes, examining only objective changes in behaviour or, better yet, changes in morbidity or mortality. Research reports should describe in detail the educational intervention employed and the target audience.

Developing Countries↗

PubMed2002

Methods for assessing quality of provider performance in developing countries.

OBJECTIVE: To compare the effectiveness of methods for assessing the quality of pediatric outpatient health provider performance in developing countries. DESIGN: Exit interviews, record reviews, and provider interview results were compared with those of direct observation of pediatric patient care. Thirty health care providers in 14 facilities in Lilongwe District, Malawi were interviewed and observed, treating 436 children in August 1994. Caretakers for 426 of the patients were interviewed, and 362 pediatric outpatient entries in the health center patient register were located and reviewed. MAIN MEASURES: Kappa statistics measuring the level of agreement on the same sample were used for three methods (record reviews, provider interviews, and exit interviews) in comparison with the fourth method, direct observation. RESULTS: All three methods had strengths and weaknesses. Exit interviews with caretakers provided reliable responses for many history-taking tasks, easily discernible physical exam tasks, and many counseling tasks. Record review took little time, but provided limited information: however, the results were reliable for treatments. Provider interviews had much lower reliability, but were usable for assessing more rare events (treating severely ill children). CONCLUSIONS: Although exit interviews and direct observation provide the 'best' data, they are most resource-intensive. Depending on the purpose of the assessment, various combinations of methods might be more effective.

Case Management↗

PubMed2001

Challenges for improving surveillance for pesticide poisoning: policy implications for developing countries.

BACKGROUND: Surveillance is a critical public health tool for the control of pesticide poisoning. However, surveillance activities in developing countries are bedevilled by multiple problems, and inferences made from review of flawed data may lead to mistaken policy decisions. METHODS: Results of intensified surveillance from an intervention project in the Western Cape Province of South Africa were compared to the pattern of poisonings reported in routine notifications to the health authorities for a control farming district and in the study district over a 5-year period preceding the study. Intensified surveillance data results were also contrasted with policy approaches based on routine notifications and on Regional Poison Centre reports. RESULTS: Poisoning rates reported in the study area increased almost 10-fold during the intervention period. Compared to intensified surveillance, hospital and health authority sources greatly underestimate the proportion of cases due to occupational poisoning, and overestimate suicide as a proportional cause. In addition, the risks for women appear underestimated from routine notifications. Assumptions that a lack of awareness is responsible for most poisonings are not borne out by the empirical data when reporting is intensified. CONCLUSIONS: Current policy assumptions are faulty, may result in inappropriate blame being attributed to victims and, by relying on information as the main element of education, may shift responsibility onto the individual. Improvements in the surveillance system should aim to restructure the types of data collected, and facilitate intra-governmental and inter-sector collaboration. The culture of monitoring based on report writing must change to one of surveillance that leads to intervention.

Adolescent↗

PubMed2005

Experience with chemoreduction and focal therapy for intraocular retinoblastoma in a developing country.

BACKGROUND: Chemoreduction is used for the treatment of retinoblastoma in industrialized nations; however, there are fewer data from developing countries. Before the implementation of this program, radiotherapy was used in almost all preserved eyes. METHODS: Retrospective evaluation from 1995 to 2001 at the Hospital Garrahan (Argentina). Carboplatin 18.7 mg/kg/day 1 and vincristine (0.05 mg/kg/day 1) were offered to patients with Reese-Ellsworth (RE) groups I-III and all unilateral cases. Etoposide (3.3 mg/kg/day 1 and 2) was added for groups IV and V. The number of cycles was tailored according to response. RESULTS: Fifty-eight patients (78 eyes) were evaluated (39 bilateral, 19 unilateral). With a median follow-up of 47 months, 40 patients had unilateral enucleation, 14 were not enucleated, and 4 had bilateral enucleation. Nineteen patients had unilateral initial enucleation. Eye preservation at 5 years was: RE groups I-III (n = 24 eyes), 0.9 (SE: 0.095) IV-V (n = 54), 0.45 (SE 0.07). Patients received a median of four cycles of chemotherapy. Acute toxicity was mild. External beam radiotherapy was avoided in 41% of eyes with groups I-III. Etoposide was avoided in 24 patients. Two patients died of metastasis. No secondary malignancy occurred. CONCLUSIONS: Compared to our previous experience, eye preservation was better and even though less radiotherapy was used, it was prescribed more often than currently recommended in eyes with less advanced disease because of limited availability of sophisticated local therapy.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2004

Nosocomial infection in a pediatric intensive care unit in a developing country.

OBJECTIVE: Determine the rate and outcome of nosocomial infection (NI) in pediatric intensive care unit patients in a developing country. DESIGN: Prospective cohort study using the Centers for Disease Control and Prevention definitions to diagnose nosocomial infection and NNISS (National Nosocomial Infection Surveillance System) methodology. SETTING: São Paulo Hospital - Universidade Federal de São Paulo - Brazil, a 700-bed teaching hospital with an 8-bed pediatric intensive care unit. PARTICIPANTS: All 515 children consecutively admitted to the pediatric intensive care unit from April 1996 to October 1997. RESULTS: The NI incidence was 18.3% and the mean infection rate per 1,000 patient days was 46.1; the ventilator-associated pneumonia rate was 18.7 per 1,000 ventilator days; the central line-associated bloodstream infection rate was 10.2 per 1,000 central line days; and the urinary tract catheter-associated infection rate was 1.8 per 1,000 catheter days. Pneumonia was the most common NI (31.6%), followed by bloodstream infections (17.3%), and surgical site infection (17.3%). Gram-negative bacterias were the most common pathogens identified in the NIs (54.8%), followed by Gram-positive bacterias (23.8%), and yeasts. CONCLUSION: Pneumonia was the most common type of NI. A high incidence of ventilator-associated pneumonia and central line-associated bloodstream infections was found, whereas the urinary tract catheter-associated infection rate was low. Gram-negative bacterias were the most common etiologic agents identified in the unit, and yeasts were frequently found. Pediatric patients have characteristics of their own, with major differences when compared to the adult population.

Brazil↗