Godfrey Walker

Medical Care in Developing Countries Assessment and Assurance of Quality

In recent years attention in developing countries has concentrated upon strategies to improve the equitable provision of essential health care-the primary health care approach. Very little work has been reported in connection with the quality of medical care, and yetfor the successful outcome of care it is necessary that adequate health care processes be carried out. Conceptual, methodological, data, and organizational issues related to quality assessment and assurance are presented. Thefew examples of reported work concerned with these important aspects of medical care in developing countries are reviewed. Suggestions are made as to how measures to ensure reasonable quality might be further developed and refined.

MATERNAL MORTALITY IN JAMAICA

A confidential inquiry into all maternal deaths in Jamaica during 3 years (1981 to 1983) was carried out. 192 maternal deaths were identified by a variety of means. The maternal mortality rate of 10.8 per 10 000 live births was considerably higher than the official rate of 4.8. The most common causes of death were hypertensive diseases of pregnancy (26%), haemorrhage (20%), ectopic pregnancy (10%), pulmonary embolus (8%), and sepsis (8%). Maternal mortality was closely related to both age and parity. The lowest rates were for women of para 2-4 aged 20-24 years and para 3-4 aged 25-29 years. The largest groups of avoidable factors were: non-use of and deficiencies in antenatal care; inadequacy in ensuring the delivery in hospital of women at high risk; and delays in taking action when signs of complications developed before, during, and after delivery.

The quality of care is related to death rates: hospital inpatient management of infants with acute gastroenteritis in Jamaica

The quality of care of random samples of about 40 infants admitted with acute gastroenteritis to each of five hospitals in Jamaica was assessed. Low levels of adherence to consensus care criteria appeared to be correlated with high levels of hospital-specific severity standardized mortality ratios X100 (SSMRs); poor adherence, SSMR 127-230; intermediate adherence, SSMR 95; good adherence, SSMR 14. The main deficiencies in care at certain hospitals were: non-weighing of infants, incomplete physical examination, inadequate estimation of fluid requirements, and irregular recording of fluid intake. To improve the effective care of infants with gastroenteritis, a quality assurance program is required.

Primary Health Care Activities: What are They?

Primary health care (PHC) has been widely accepted as an approach which acknowledges that to improve the health status of the majority of people necessitates changes in their social and economic circumstances, rather than the provision of orthodox comprehensive health care. While it does not deny the important contribution of health care services the implication of this acceptance is vast. Consequently the activities of PHC go far beyond what have conventionally been considered immediate concerns in the organization of health care. The traditional tropical “medical officer” often included nutrition, safe water and basic sanitation as health sector activities, and these have once again been accepted by many involved in implementing PHC. But there remain others who have not fully appreciated the scope and implications of PHC, considering it to consist essentially of an extension of basic health services with or without the addition of a new cadre of health auxiliary the village or community health worker (UNICEF-WHO 1981). In fact it involves considerably more than this. The major areas for action proposed for PHC were set out at the Alma Ata conference (WHOUNICEF 1978). Here it was stated that it would “. . . address the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly”. The components of PHC were seen to include at least: ( 1 ) promotion of proper nutrition (2) provision of an adequate supply of safe water (3) provision of basic sanitation (4) maternal and child care, including family planning ( 5 ) immunization against the major infectious diseases (6) prevention and control of locally endemic diseases (7) education concerning prevailing health problems and the methods of prevention and control (8) appropriate treatment €or common diseases and injuries. It should be noted that the non-health sector activities are stated first; then promotive and preventive e.g. maternal and child health care, immunizations etc.; and lastly come curative (treatment) activities, For the successful implementation of PHC it was argued that there was a substantial requirement for community participation in deciding local priorities, acceptable actions, and support by more formal organizations especially in the health sector but also collaboration and coordination of efforts with other sectors, notably agriculture, housing, education and water and sanitation. Even a fairly cursory examination of these goals shows that many different actions are required if PHC is to be successful. The activities associated with PHC can be considered in three main areas: coordination and collaboration with other sectors; local communities’ involvement in improving their own health situation; support of this by the formal (or government) health sector. These activities must occur at various levels within the country concerned. These are essentially the local community, the peripheral administrative, and the national or regional level. Much of the preliminary work concerned with PHC has been directed towards health sector planning (national and regional) and medical care aspects (local community). This has often concentrated upon the desirability of training and providing village health workers. For village health workers to be able to undertake their higher priority work, i.e. promotive and preventive health activities, it has frequently been found that they must provide credible basic curative care. A necessary aspect of this is that they receive regular appropriate provision of essential drugs and supplies (support by the health sector).

Alternative forms of transport and their use in the health services of developing countries.

During the past few years greater interest has been shown in ways in which the coverage of health services in developing countries might be increased. Frequently, it has been advocated that greater use be made of mobile health services, often using relatively sophisticated transport systems, including aircraft. The present article examines the uses to which mobility in health services has been put and the merits of different forms of transport, within the resource constraints and health “needs” of Third World countries. Our main conclusions are that for the majority of health service movement appropriate intermediate technology transport should be used (i.e. bicycle, animals, or motorcycles). The use of mechanical transport within health services with the highest benefit per unit cost is likely to be that employed in the regular supportive (not policing) visits to permanently staffed fixed basic care facilities by more highly skilled and scarce health personnel. Those clinics located closer to the regional base can usually be reached more cheaply by land transport, while those at a distance might justify the use of a light aircraft. Where aircraft are used in this supportive role, it is important they are integrated into the ongoing health services and tightly scheduled to lessen the risk of their diversion to less cost-effective activities.

Transport and communication systems in health services.

During the past few years greater interest has been shown in ways in which the effectiveness of basic health services might be increased. One of the major areas ofdifficulty in most developing countries is poor communication systems between health headquarters (regional and district) and more peripheral u.nits. Rural clinics and dispensaries are often relatively isolated. Owing to difficulties in communications the staff of these units are frequently forced to accept a chronic shortage of even basic medical supplies. For similar reasons referral systems are often virtually non-existent. Local communities understandably question the worth of care that is dispensed from such isolated and ill-equipped facilities.

Estimating coverage from routine information.

A study was conducted in Buhera district, Zimbabwe, to estimate coverage of health services by relating routinely collected health statistics to census data. Buhera is a relatively underdeveloped district, with health services provided by a district hospital, 2 rural hospitals, 12 health centers and 50 mobile clinics. Data were collected concerning the number of individuals making outpatient visits, antenatal visits and vaccinations per month for each catchment area. Overall, there were 69 new outpatient visits/100 people in the catchment area per year. Several areas were found to have much lower rates, and this was linked to areas with high membership in the Apostolic Church, a group that forbids medical treatment. There were 43 new antenatal visits/100 pregnancies. Low rates were linked to areas with no female medical assistants. 32% of children under 1 year of age were vaccinated against measles. Low vaccination rates were linked to Apostolic Church membership. In a cluster survey, 36% of respondents cited religious beliefs as the reason for incomplete immunization. Routine health statistics were found to underestimate vaccination rates by 25%. This was attributed to incomplete recording and forms being lost. Analysis of routine data is believed to provide useful information that may allow identification of underserved areas and of barriers to health care utilization.

Book Review: The Field Directors' Handbook: An Oxfam Manual for Development WorkersThe Field Directors' Handbook: an Oxfam Manual for Development Workers (1985 pp 512£9.95 OUP for Oxfam ISBN 0 19 920153 6)

Breathing and Warmth at Birth: Judging the Appropriateness of Technology edited by G Sterky, N Tafari and R Tunell (SAREC report R 2:1985 pp 159 price not stated Swedish Agency for Research Cooperation with Developing Countries. S-105 25 Stockholm ISSN 03482626) Much attention has been focused recently on the unacceptably high infant mortality rates (IMR) prevalent in developing countries. In 1982 there were 43 countries with very high IMR of 110-200 per 1000 live births, and 29 countries with IMR of 60-100 per 1000 live births. All 72 countries were located in Africa, Asia, the Middle East and Latin America. An analysis of infant mortality in these countries shows that about half of these deaths occur around the time of birth and during the first month of life. This high loss of life in the perinatal and neonatal periods is known to have a negative effect on the acceptance of family planning in Asia and Africa. As a consequence, care of the newborn infant has become an increasingly important component of mother and child care in developing countries. Safe childbirth is an integral part of primary health care in all countries, this service being provided mainly by traditional birth attendants who have received varying degrees of training. Basic and essential care of the newborn baby consists of the establishment of respiration, maintenance of body temperature and breastfeeding. Breastfeeding in developing countries has been studied and given much publicity. However, breathing and warmth at birth have received lessattention. It is therefore exciting to see this report of a seminar on appropriate technology for newborn care, held in Stockholm in 1984 and attended by scientists and health workers from developing and industrialized countries. This book contains both the theory and practice of neonatal resuscitation and thermoregulation appropriate for developing countries, with case reports from China, Ethiopia, the Philippines and Turkey, as well as research from the industrialized world. Background information includes culture and neonatal technology, and a survey of traditional neonatal practices. Asphyxia at birth and hypothermia are frequently encountered in the tropics. The workshop reached an important consensus on assessment of the newborn, resuscitation procedures and provision of warmth. These sections are printed on yellow pages for easy reference. Respiration and heart rate are the two essential indicators of neonatal wellbeing at birth. A score based on three parameters has been devised as a simple and accurate assessment of the need for resuscitation. A birth record of basic information on the health of the newborn has been produced. BOOK REVIEWS I 95