Reinhard Huss

Dopamine-induced diuresis in the cat without changes in renal hemodynamics.

SummaryThe effects of intravenous (i.v.) and intraarterial (i.a.) injection and infusion of dopamine (DA) on renal hemodynamics, regional sympathetic activity and kidney function were investigated in anaesthetized cats. In response to the i.v. bolus injection of DA (25 μg/kg), mean arterial blood pressure (MABP) was increased by 19.7%, renal blood flow (RBF) by 16.6%, and regional sympathetic discharges were inhibited. The principal effect of i.a. bolus injection of DA into the renal artery was vasoconstriction. Vasodilation was observed neither after lower doses of DA nor after pretreatment with phenoxybenzamine.During continuous i.v. infusion of 10 μg DA kg−1 min−1 MABP, RBF, renal sympathetic discharges and glomerular filtration rate (GFR) did not change, whereas urine volume was increased by 120.5%, sodium excretion by 99.7%, chloride excretion by 143.2%, and potassium excretion by 31.9%. Urine osmolality was decreased and osmolal clearance increased. Raising the DA dose to 25 μg kg−1 min−1 resulted in a fall of GFR, but the diuretic response was not significantly different from that of the low dose. Bulbocapnine (6 mg/kg i.v.) antagonized the DA-induced diuresis.In conclusion, the diuretic effect of DA in the cat is not dependent on a change in RBF, GFR or renal sympathetic activity. This suggests that a tubular site of action is primarily responsible for DA diuresis.

Blindness and visual impairment in a region endemic for onchocerciasis in the Central African Republic

AIMS A population based survey of blindness and visual impairment was conducted in the district of Bossangoa, Central African Republic. Methods—A total of 48 communities were randomly selected, and 6086 people examined. RESULTS The prevalence of blindness (visual acuity in the better eye less than 3/60) was 2.2%, and visual impairment 3.0% (6/24 to 3/60 in the better eye). The major causes of blindness were onchocerciasis (73.1%), cataract (16.4%), trachoma (4.5%), and glaucoma (2.2%). CONCLUSION Around 95.5% of all blindness could potentially have been prevented or treated. Ivermectin mass distribution is hoped to prevent 50% of all forms of visual loss in the future.

Herpes zoster as an indicator of HIV infection in Africa.

In areas where resources for health information are limited, the incidence of herpes zoster can usefully be monitored as an indicator of HIV infection. A sudden parallel rise of the number of symptomatic HIV cases and herpes zoster cases was observed in a northern district of Zimbabwe. Herpes zoster was made locally reportable. Three years later the incidence of herpes zoster and HIV in the hospital and of herpes zoster in the surrounding rural health centres was analysed. The herpes zoster attack rate and the HIV seropositivity rate of herpes zoster patients resembled those elsewhere in Africa. The distribution of cases of zoster was comparable with that of HIV infection.

Good governance and corruption in the health sector: lessons from the Karnataka experience

Strengthening good governance and preventing corruption in health care are universal challenges. The Karnataka Lokayukta (KLA), a public complaints agency in Karnataka state (India), was created in 1986 but played a prominent role controlling systemic corruption only after a change of leadership in 2001 with a new Lokayukta (ombudsman) and Vigilance Director for Health (VDH). This case study of the KLA (2001-06) analysed the:Scope and level of poor governance in the health sector; KLA objectives and its strategy; Factors which affected public health sector governance and the operation of the KLA. We used a participatory and opportunistic evaluation design, examined documents about KLA activities, conducted three site visits, two key informant and 44 semi-structured interviews and used a force field model to analyse the governance findings. The Lokayukta and his VDH were both proactive and economically independent with an extended social network, technical expertise in both jurisdiction and health care, and were widely perceived to be acting for the common good. They mobilized media and the public about governance issues which were affected by factors at the individual, organizational and societal levels. Their investigations revealed systemic corruption within the public health sector at all levels as well as in public/private collaborations and the political and justice systems. However, wider contextual issues limited their effectiveness in intervening. The departure of the Lokayukta, upon completing his term, was due to a lack of continued political support for controlling corruption. Governance in the health sector is affected by positive and negative forces. A key positive factor was the combined social, cultural and symbolic capital of the two leaders which empowered them to challenge corrupt behaviour and promote good governance. Although change was possible, it was precarious and requires continuous political support to be sustained.

Can action research strengthen district health management and improve health workforce performance? A research protocol

Introduction The single biggest barrier for countries in sub-Saharan Africa (SSA) to scale up the necessary health services for addressing the three health-related Millennium Development Goals and achieving Universal Health Coverage is the lack of an adequate and well-performing health workforce. This deficit needs to be addressed both by training more new health personnel and by improving the performance of the existing and future health workforce. However, efforts have mostly been focused on training new staff and less on improving the performance of the existing health workforce. The purpose of this paper is to disseminate the protocol for the PERFORM project and reflect on the key challenges encountered during the development of this methodology and how they are being overcome. Methods The overall aim of the PERFORM project is to identify ways of strengthening district management in order to address health workforce inadequacies by improving health workforce performance in SSA. The study will take place in three districts each in Ghana, Tanzania and Uganda using an action research approach. With the support of the country research teams, the district health management teams (DHMTs) will lead on planning, implementation, observation, reflection and redefinition of the activities in the study. Taking into account the national and local human resource (HR) and health systems (HS) policies and practices already in place, ‘bundles’ of HR/HS strategies that are feasible within the context and affordable within the districts’ budget will be developed by the DHMTs to strengthen priority areas of health workforce performance. A comparative analysis of the findings from the three districts in each country will add new knowledge on the effects of these HR/HS bundles on DHMT management and workforce performance and the impact of an action research approach on improving the effectiveness of the DHMTs in implementing these interventions. Discussion Different challenges were faced during the development of the methodology. These include the changing context in the study districts, competing with other projects and duties for the time of district managers, complexity of the study design, maintaining the anonymity and confidentiality of study participants as well as how to record the processes during the study. We also discuss how these challenges are being addressed. The dissemination of this research protocol is intended to generate interest in the PERFORM project and also stimulate discussion on the use of action research in complex studies such as this on strengthening district health management to improve health workforce performance.

A method to determine the coverage of ivermectin distribution in onchocerciasis-control programmes.

Onchocerciasis is a human filarial infection responsible for an estimated 750,000 blind and severely visually disabled people. In some African countries, this disease represents the main cause of blindness, with considerable socio-economic impact on the affected communities. Since the introduction of ivermectin as a microfilaricidal agent, there is hope that visual loss from onchocerciasis can be eliminated through community-based ivermectin-distribution programmes. The African Programme for Onchocerciasis Control (APOC) has now been initiated, by the World Health Organization and World Bank, to distribute ivermectin in 19 African countries where onchocerciasis is endemic. Estimates of ivermectin coverage in distribution programmes for onchocerciasis control have so far been based on the number of treatments given, in any one year, to a target population. There is a need for a standardized method to evaluate, measure and monitor coverage over time. In April 1996, a cluster random-sampling method was used to calculate coverage with ivermectin in an urban population of 30,000 people in the Central African Republic. The method was adapted from that used to determine coverage by the WHO Expanded Programme on Immunization. It proved to be inexpensive and easy to perform, requiring only local equipment and personnel. The method used and results obtained in Bossangoa and the potential use of the technique in other distribution programmes are discussed.

Species Differences of Dopaminergic Vasodilation in the Intestine

ABSTRACT The effects of i.v. dopamine (DA) infusion on regional splanchnic blood flow were investigated in anaesthetized cats (consecutive doses of 5, 10, 25 µg kg−1 min−1) and rabbits (10, 20, 50 µg kg−1 min−1). The cats were additionally given DA as a bolus injection (25 µg/kg i.v. and i.a.) and as i.a. infusion in the superior mesenteric artery. In the feline mesenteric circulation the regular flow response to bolus injection was initial vasoconstriction and subsequent vasodilation, vasoconstriction being stronger after i.a. than after i.v. injection. Regional pre- and postganglionic sympathetic discharges were at first inhibited and arterial blood pressure rose. During the delayed period of vasodilation, blood pressure fell and regional sympathetic activity increased. Primary vasoconstriction was blocked by phenoxybenzamine (5 mg/kg i.a.). Subsequent vasodilation was markedly attenuated by haloperidol (5-8 mg/kg i.v.) and blocked by bulbocapnine (5 mg/kg i.v.), but not by propranolol (2-4 mg/kg i.v.). Continuous i.v. and i.a. infusion of DA elicited a dose dependent increase of superior mesenteric blood flow without a decrease in regional sympathetic activity. During i.v. infusion of the highest DA dose in cats, resistance to flow in the inferior mesenteric vascular bed fell by 74.4 ± 14.5% (mean ±SD; n = 10), in the superior mesenteric artery bed by 51.7 ±9.6%; no significant changes were noted in the region supplied by the coeliac artery. This is in contrast to rabbits, where vascular resistance decreased especially in the coeliac (by 67.6 ±10.1%) and superior mesenteric (by 32.1 ±13.3%), but not in the inferior mesenteric region. Infusion of DA had no distinct vasodilator effect on the renal and femoral circulations of cats and rabbits. The results conceivably indicate the existence of specific postsynaptic DA receptors in the intestine of cats and rabbits which mediate the selective vasodilation. It is postulated that DA might be involved in local regulation of intestinal blood flow.

Contextual influences on the role of evidence in health policy development: insights from India and Nigeria

Background The context is a complex and important influence on decision-making, affecting degree of responsiveness and people-centred health systems. Although theoretical frameworks to understand context are available, limited empirical research exists exploring contextual influences on evidence-informed health policymaking. This presentation compares contextual influences on the role of evidence in health policy development within two large countries within their continents: India and Nigeria.

Managing pharmaceuticals in international health

1 Issues in the Management of Pharmaceuticals in International Health.- 1.1 Introduction.- 1.2 Pharmaceuticals, medicines and drugs.- 1.3 International health.- 1.4 The emergence of medicines.- 1.5 Global inequity and the medicines life cycle.- 1.6 The study of pharmaceuticals in international health.- 1.7 Approaches to managing pharmaceuticals.- 1.8 Layout of the book.- 1.9 Conclusion.- 2 Access and Availability of Pharmaceuticals in International Health.- 2.1 Introduction.- 2.2 Access to essential medicines.- 2.3 Neglected diseases.- 2.4 Strategies for developing medicines and ensuring access.- 2.5 Conclusion.- 3 Assessing the Pharmaceutical Needs of Patients and Populations.- 3.1 Introduction.- 3.2 Public health pharmacology.- 3.3 Incidence of disease.- 3.4 Needs and priorities for medicines.- 3.5 Culture and the use of medicines.- 3.6 Patients as consumers.- 3.7 Compliance, adherence and concordance.- 3.8 Empowerment.- 3.9 Conclusion.- 4 The Role of Health Professionals.- 4.1 Introduction.- 4.2 Classifying health professionals.- 4.3 Health professionals and medicine responsibilities.- 4.4 The role of the doctor.- 4.5 The role of the pharmacist.- 4.6 Traditional healers.- 4.7 Integrating traditional medicine and Western medicine.- 4.8 Conclusion.- 5 The Role of the Pharmaceutical Industry.- 5.1 Introduction.- 5.2 The origins and development of the pharmaceutical industry.- 5.3 Structure of the industry today.- 5.4 Pharmaceutical company partners.- 5.5 The activities of the industry.- 5.6 Pharmaceutical markets.- 5.7 The pharmaceutical industry and international health.- 5.8 Conclusion.- 6 The Role of Governments.- 6.1 Introduction.- 6.2 The development of national drug policies.- 6.3 The drug supply process.- 6.4 Health systems that support drug supply.- 6.5 Pharmaceutical legislation and regulation.- 6.6 Research, monitoring and evaluation.- 6.7 Conclusion.- 7 The Role of the European Union, National Assistance Agencies and NGOs.- 7.1 Introduction.- 7.2 The European Union.- 7.3 The national aid agencies.- 7.4 International and national NGOs.- 7.5 Some non-governmental organizations.- 7.6 Equitable pharmaceutical supply and distribution.- 7.7 Conclusion.- 8 The Role of International Organizations.- 8.1 Introduction.- 8.2 WHO and other UN organizations.- 8.3 Industry organizations.- 8.4 Other organizations.- 8.5 Essential drugs.- 8.6 Pharmaceutical procurement.- 8.7 International agreements and intellectual property rights.- 8.8 Case study-HIV/AIDS and antiretroviral treatment in South Africa.- 8.9 Conclusion.- 9 Rational Use of Medicines.- 9.1 Introduction.- 9.2 Consequences of non-rational medicine use.- 9.3 Medicine use behaviour.- 9.4 Investigating medicine use problems.- 9.5 Medicine use interventions.- 9.6 Effectiveness of interventions.- 9.7 Conclusion.- 10 Medicine Quality, Adverse Reactions and Antimicrobial Resistance.- 10.1 Introduction.- 10.2 Quality of medicines.- 10.3 Counterfeit medicines.- 10.4 Adverse drug reactions.- 10.5 Antimicrobial resistance.- 10.6 Conclusion.- 11 Managing Medicines Information.- 11.1 Introduction.- 11.2 The users of medicine information.- 11.3 Sources of information.- 11.4 The quality of medicines information.- 11.5 The assessment of information.- 11.6 Classification systems.- 11.7 Conclusion.- 12 Investigating the Use of Medicines.- 12.1 Introduction.- 12.2 Drug utilization studies.- 12.3 Pharmacoeconomics.- 12.4 Pharmacovigilance.- 12.5 Pharmacoepidemiology.- 12.6 Health systems and policy studies.- 12.7 Conclusion.- 13 Trends and Developments.- 13.1 Introduction.- 13.2 Trends in the use of herbal remedies.- 13.3 The contribution of pharmacogenetics and pharmacogenomics.- 13.4 The changing role of the internet.- 13.5 Changes in the health care workforce.- 13.6 Conclusion.- 14 Policy Initiatives and their Implications.- 14.1 Introduction.- 14.2 The role of public-private partnerships.- 14.3 The Global Fund and other initiatives.- 14.4 Global procurement of medicines.- 14.5 AIDS drugs post Doha.- 14.6 Conclusion.- Selected Websites and Webportals.

Study protocol: realist evaluation of effectiveness and sustainability of a community health workers programme in improving maternal and child health in Nigeria

BackgroundAchievement of improved maternal and child health (MCH) outcomes continues to be an issue of international priority, particularly for sub-Saharan African countries such as Nigeria. Evidence suggests that the use of Community Health Workers (CHWs) can be effective in broadening access to, and coverage of, health services and improving MCH outcomes in such countries.Methods/designIn this paper, we report the methodology for a 5-year study which aims to evaluate the context, processes, outcomes and longer-term sustainability of a Nigerian CHW scheme. Evaluation of complex interventions requires a comprehensive understanding of intervention context, mechanisms and outcomes. The multidisciplinary and mixed-method realist approach will facilitate such evaluation. A favourable policy environment within which the study is conducted will ensure the successful uptake of results into policy and practice.A realist evaluation provides an overall methodological framework for this multidisciplinary and mixed methods research, which will be undertaken in Anambra state. The study will draw upon health economics, social sciences and statistics. The study comprises three steps: (1) initial theory development; (2) theory validation and (3) theory refinement and development of lessons learned. Specific methods for data collection will include in-depth interviews and focus group discussions with purposefully identified key stakeholders (managers, service providers and service users), document reviews, analyses of quantitative data from the CHW programme and health information system, and a small-scale survey. The impact of the programme on key output and outcome indicators will be assessed through an interrupted time-series analysis (ITS) of monthly quantitative data from health information system and programme reports. Ethics approvals for this study were obtained from the University of Leeds and the University of Nigeria.DiscussionThis study will provide a timely and important contribution to health systems strengthening specifically within Anambra state in southeast Nigeria but also more widely across Nigeria. This paper should be of interest to researchers who are interested in adapting and applying robust methodologies for assessing complex health system interventions. The paper will also be useful to policymakers and practitioners who are interested in commissioning and engaging in such complex evaluations to inform policies and practices.