Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Re: Building the equity gap in maternal and child health
- Tolulola Taiwo (15 September 2005)
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Lay health workers may contribute to reducing inequities in global maternal and child health
- Simon Lewin (16 September 2005)
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Health Systems Research for improved implementation - not more of the same
- Øystein E Olsen (16 September 2005)
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It is a question of societal change and political will
- Saad H. Bashir (18 September 2005)
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Communication vs information
- Albert Figueras (18 September 2005)
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Partnerships can be part of the solution
- Anthony G Dunnett (19 September 2005)
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Towards achieving the "Millennium Development Goals"
- Dr. Rajesh Chauhan, Dr. Akhilesh Kumar Singh, MD; Dr. Parul Kushwah, MBBS, MISMCD; Sandeepa Chauhan; Shruti Chauhan. (1 October 2005)
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Re: Towards achieving the "Millennium Development Goals"
- Dr. Rajesh Chauhan, Dr. Akhilesh Kumar Singh, MD, Dr. Parul Kushwah, MBBS, MISMCD, Sandeepa Chauhan, Shruti Chauhan, and Shivendra Pratap Singh Chauhan. (2 December 2006)
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Tolulola Taiwo, Medical resident University of Alberta, Edmonton, AB, Canada
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In this article, Bhutta1 emphasised the importance of relevant cost- effective resaerch and interventions in dealing with the health inequities faced by maost developing countries. Several studies have already been conducted in Africa. While, the proportion of these studies is miniscual compared with the research that is continually being undertaken across the western world, the issue lies not conducting research but mainly with implementing the outcomes of the studies. In addition, tools to effectively monitor and evaluate existing programs are lacking in many developing countries. In Africa, the past two decades have witnessed decreased government funding on agriculture, education and healthcare.2 This has led in large part of the crumpling health infrastructure across the continent. Thia has been partly blamed on the policies of international agenies , such as the World Bank and International Monetary Fund (IMF). However, the failure of governments to be proactive in recognising health needs of their populations and developing effective and efficient interventions should not be overlooked. Health indicators looking at the burden of disease continue to show little or no progress. This reaffirms the need to re-evaluate the ways of dealing with health challenges. I concur with Bhutta's suggestions that programmes need to be relevant in addressing health inequities. Addressing the needs of the populations as well as the major obstacles to health should be a priority. In Nigeria, for example, people have to pay out-of-pocket medical expenses. How can a person who can barely afford to feed his family pay for his wife's antenatal care? In this regard, preventive healthcare takes a backseat to more pressing issues, such as the next meal. For any meaning successes in addressing health inequities, interventions aimed at improving health indices should be in conjunction with education and agriculture development programs. References: 1. Bhutta ZA. Briding the equity gap in maternal and child health. BMJ, DOI: 10.1136/BMJ.38603.5266444.47. 2. Martin G, Shisana O. HIV/AIDS spending in Southern Africa well below requirements for prevention, care and treatment.Nov, 10, 2003. www.hsrc.ac.za/media/2003/11/2003110.pdf Tolulola Taiwo M.B.,B.S, MPH Competing interests: None declared |
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Simon Lewin, Lecturer London School of Hygiene and Tropical Medicine and Medical Research Council of South Africa
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As Bhutta has noted, the problem of ensuring appropriate human resources within health services remains acute in many low and middle income countries. The renewed interest in community or lay health worker (LHW) programmes is partly a result of this, and also of the growing understanding of the important roles that can be played by lay people in supporting treatment and care for people with HIV/AIDS, TB and many other chronic illnesses. Bhutta rightly notes that more research and reviews in this area are needed. In this regard, I would like to draw attention to a recently completed Cochrane systematic review of the effects of LHWs in primary and community health care(1). To our knowledge, this is the first attempt to summarise the global evidence from RCTs on the effectiveness of such interventions. Based on 43 trials, it shows that LHWs demonstrate promising benefits in certain areas, for example in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. It also highlights a wide range of other health issues for which evidence of the effectiveness of LHW programmes is insufficient to justify recommendations for policy and practice. LHWs have the potential to contribute to reducing inequities in global maternal and child health, but further rigorous studies of their impacts, sustainability and transferability, as well as the factors affecting the scaling up of such programmes, are needed urgently. We hope that this review will help to focus this research where it is most needed. 1. Lewin SA, Dick J, Pond P, Zwarenstein M, Aja G, van Wyk B, Bosch- Capblanch X, Patrick M. Lay health workers in primary and community health care. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004015. DOI: 10.1002/14651858.CD004015.pub2. Competing interests: None declared |
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Øystein E Olsen, Senior Health Systems Research Advisor Primary Health Care Institute, Iringa, Tanzania
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I fully concur with the overall challenges addressed by Z.A Bhutta. As a participant in the Mexico Global Forum for Health Research my anticipation was high regarding research that is focused on assisting in bridging the equity gap.
As an advisor to district health managers on priority setting, I am concerned however with the constant return to a call for more research on cost-effectiveness as the solution to improved implementation of health services in developing countries. Cost effectiveness information is useful, but far from adequate when a district health manager needs to make a decision and include stakeholders for priority setting. To know if one intervention against Malaria is more cost effective than another against HIV/AIDS, is for all practical purposes useless information to a district policy maker. This type of information is only really useful when she has to choose between two interventions tackling the same challenge. The district health manager is up against a range of stakeholders, all with differing values and criteria for the priority setting process. Cost effectiveness is only one of them [1]. Unless we provide her with tools to also measure and include other values such as equity, trust and human rights, we can not expect that the priorities reached will be trusted nor implemented by the various stakeholders. More research is therefore needed on how to ensure trust and equity, even at the possible expense of cost effectiveness. We are trying to contribute to this type of research using the Accountability for Reasonableness [2, 3] framework in Tanzania, Zambia and Kenya [4]. The same framework is also being assessed in terms of its usefulness to district health managers in Tanzania, in which we are aiming at providing capacity building for fair priority setting [5]. It is meaningless to assume that the current allocated funds towards health care provision will adequately tackle even the most important challenges, and we therefore need information on how much will it cost to provide e.g. equitable and trustworthy services. This is useful for planning and advocacy purposes. Presenting a priority list of interventions based solely on cost effectiveness information is like presenting a budget with running costs only, turning a blind eye to the real costs of the depreciating value of capital investments (e.g equity, trust and human rights). From the point of view of a district health manager it is therefore evident that more of the same is not the answer. They need research and tools enabling them to implement efficient interventions through a priority setting process that is fair. Assuming for example, that increased use of community health workers rather than medical personnel (as exemplified by Bhutta) to tackle challenges such as maternal mortality might be exactly the opposite of what is needed to address equity and trust [6]. The values and criteria behind the priorities set need to be explicit and with a wide ownership among the stakeholders affected. 1. Kapiriri, L. and O.F. Norheim, Criteria for priority-setting in health care in Uganda: exploration of stakeholders' values. Bull World Health Organ, 2004. 82(3): p. 172-9. 2. Daniels, N., Accountability for reasonableness. BMJ, 2000. 321(7272): p. 1300-1301. 3. Daniels, N., M. Crawford, and J.E. Sabin, Dialogue. Resource allocation: to those in the greatest need or those who will benefit most? Behav Healthc Tomorrow, 1997. 6(4): p. 52-7. 4. Olsen, Ø.E. and J. Byskov, Strengthening fairness and accountability in priority setting for improving equity and access to quality health care at district level in Tanzania, Kenya and Zambia. 2004, DBL Institute for Health Research and Development: Copenhagen. p. 48. 5. PHCI, Capacity building needs assessment for fair priority setting in health care at district level through a zonal training centre in Tanzania. 2005, Primary Health Care Institute, Iringa DBL - Institute for Health Research and Development: Iringa, Tanzania. p. 12. 6. Olsen, O.E., S. Ndeki, and O.F. Norheim, Human resources for emergency obstetric care in northern Tanzania: distribution of quantity or quality? Hum Resour Health, 2005. 3: p. 5. Competing interests: None declared |
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Saad H. Bashir, Associate Professor, Neurosurgery Aga Khan University, Karachi, Pakistan 74800
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The BMJ is one medical journal that has raised the issue of inequalities in health from the level of a discussion considered relevant only for charities to a major international concern for doctors and health care planners. The leading article by ZA Bhutta is the latest in a series of such pieces in the BMJ. The issue remains topical and one has to agree with most of the points raised. These must be familiar to the readers of the journal. However what the article focuses on are the tools of alleviating the problem. What is needed is the political will and the willingness to change within communities. Without these the tools and mechanisms to effect the desired changes remain, at best, symptomatic treatment and, sadly, futile. Despite some local, limited successes, the history of such measures is one of abject failure. The reason remains the same as well:the inability and/or unwillingness of communities to change. The only way for this to happen is for the fundamental beliefs of societies to change - a tall order indeed. Everyone does not have to follow the "Western" model of "development" but the essential requirements of societal improvement have remained and will remain the same: equal human rights for all and rational inquiry. It is the extent of internalization and application of these that determines how a community or indeed humanity progresses (no matter how progress is defined.) The rest follows on its own. Therefore, though resources need to be spent on measures mentioned by the author and others, the main thrust in the "underdeveloped" world has to be on education of human values and taking responsibility for its own future. None of this is meant to diminish the importance of the work mentioned in the article, but to say that all this will be futile without equal, if not greater, stress on the action mentioned above. Saad H. Bashir, Associate Professor, Neurosurgery, Aga Khan University, Karachi, Pakistan, saad.bashir@aku.edu Competing interests: None declared |
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Albert Figueras, International Cooperation Area Fundació Institut Català de Farmacologia. Hospital Vall d'Hebron. E-08035-Barcelona (Spain)
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Dear Editor, ZA Bhutta [1] highlights the importance of health systems research an action in order to bridge the gap in maternal and child mortality (and probably other health issues). Many publications echo disparities in wealth and health among countries. Access to medicines, drugs costs or lack of research addressed to “the diseases of the poor” are arguments frequently used to explain these gaps. Although being true, probably these arguments are just a part of the whole picture, and perhaps a wider and critical vision is necessary. The answer to three questions could be useful to re-think such problems: (1) The WHO Essential Medicines List aims to ensure appropriate drug treatment for the most common diseases; why some public health systems in developing countries frequently do not have supplies of essential medicines but expensive (and sometimes irrational) drugs are available? (2) The management of some diseases and health problems that contribute to increase infant and maternal mortality rates has been well-established and is cheap; why simple messages (such as washing hands, preparing oral rehydration solutions, or rationalize the use of antibiotics) are not reaching health professionals, community workers and general population, but many of them know the benefits of, lets say, statins to lower cholesterol? (3) Most public health institutions from less developed countries are facing serious budgetary problems due to drug expenditure; why ineffective drug expenditure (i.e., drug expenditure due to the prescription of irrational drugs, inappropriate dosages, etc.) continues to be so high in these countries –and little or null efforts are devoted to identify, to quantify and to solve these problems? In the same BMJ issue (Sept. 17th), the Education and debate paper by Raine et al. [2] discuss the need to slightly change the approach to develop clinical guidelines in order to improve coverage and make decisions more transparent. The News section of the Sept. 17th issue also includes a text entitled “Poor management, not drug costs, is hampering implementation of NICE guidance” [3]; it seems that, in England, poor financial management and not the cost of drugs and treatment is preventing clinicians from doing their jobs properly, and the Audit Commission advises better communication between clinical and financial staff in order to improve this situation. These three papers have a common denominator: medicines and information. Despite the North-South internet gap, access to medical information is relatively easy from any part of the world. Bibliographic databases, abstracts or full-text articles can be retrieved from any ciber with high- speed connection, both in developed and less-developed countries, in a country’s capital or in small towns. At present, access to information seems not to be the real problem, but the impressive amount of information that can create anxiety or, paradoxically, disinformation due to the human impossibility to process all new data. In front of this huge amount of information and evidences, efforts to improve and updating professionals' knowledge is the real challenge, and perhaps the best way to attain this objective consists in developping a sort of "emotional" information (i.e., communication). Regarding public health and use of medicines, a possible way to obtain this consists in empowering health professionals and health managers in order to assess their own actual clinical practice, and to contrast it with published evidences, with the help of continuous medical education programs developed by public health authorities. Involving health professionals in their own clinical audit and adaptation of guidelines to their midst, can help to avoid inappropriate prescriptions that, in turn, ineffectively increase drug expenditure, and help to reduce access to really essential medicines. At present, the GIRMMAHP initiative (the Catalan acronym for International Group for Reducing Maternal Mortality Associated to Postpartum Haemorrhage) is finishing the long-term impact data collection process before the publication of the final results. GIRMMAHP is an intervention funded by the Agència Catalana de Cooperació Internacional aimed at analysing the actual management of delivery practices in selected capital and rural hospitals of Nicaragua, Peru, Dominican Republic, North- East of Argentina and Guatemala in order to begin an educative intervention to develop and to implement clinical guidelines for postpartum haemorrhage (PH) prevention and management. Information on more than 2000 deliveries showed that besides a generalised lack of clear information on PH in clinical records before the intervention, there were generalised lack of identification of risk factors for PH, high maternal anaemia rates in some countries, excessive use of ergometrine in tropical climates, high inappropriate use of antibiotics, and high episiotomia rates. Research on health systems and appropriate action derived from the results of such research, as well as knowledge transference to carry out these kind of interventions and improve scientific communication (not only information) could certainly help to bridge equity gaps. References: 1. Bhutta ZA. Bridging the equity gap in maternal and child health. BMJ 2005; 331:585-6. 2. Raine R, Sanderson C, Black N. Developing clinical guidelines: a challenge to current methods. BMJ 2005; 331:631-3. 3. O’Dowd A. Poor management, not drug costs, is hampering implementation of NICE guidance. BMJ 2005; 331:594. The participants of the GIRMMAHP Project are: A Camilo, A Figueras, E Narváez, JM del Valle, M Valsecia and S Vásquez (Researchers), and G Rojas, E Castro, R Chaves, and L Bidó (Data collection coordination). The GIRMMAHP Project received two grants from the ACCD-Generalitat de Catalunya (Catalan Government) in 2003 and 2004. Competing interests: None declared |
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Anthony G Dunnett, President, International Health Partners Beech Hill, East Sussex, TN5 6JR
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Dear Sir The scale of the challenges facing maternal health in Africa can be bewildering. However, significant additional help can be provided by tapping into the skills, expertise and resources available from within the UK medical community, industry and concerned healthcare professionals. One example of what can be achieved can be seen following on from the BBC panorama documentary this past summer. The programme focused on the plight of Chad's public health system in general and, in particular, on the maternity wing of the main Hopital de Reference Nationale in the capital N'Djamena. Chad almost tops the league tables for the world's worst maternal care (ranking 173 out of 177 countries in the UNDP 2005 Human Development Index). If you are a woman in Chad today there is a 1 in 11 chance that you will die in pregnancy or childbirth. The estimated maternal mortality rate is 827/100,000 (Source: UNFPA). For a population of 9.3 million, there are just 18 obstetricians, including four United Nations Volunteers. Only 16% of births in Chad are attended by skilled personnel (Source: UNICEF). With there being virtually no international NGOs operating healthcare in Chad, other than working with the refugees from Dafor in the North East, there is a chronic need for medicines and public/maternal healthcare training. One group of committed individuals have got together to provide a coordinated response to assist the main hospital in N’Djamena. Working with the Ministry of health, the hospital and the few international medical professionals in the area, the group has sought to first identify the specific needs for healthcare supplies. The training and capacity building needs will be reviewed over the coming weeks, with a view to establishing a long-term partnership between a UK hospital and maternity provision in the capital. Each journey of 1000 miles starts with one step. Those traveling must have fortitude. It is essential that the destination is determined by those on the ground who have responsibility for, and fully understand the needs. Similarly, the provisions for the journey must be driven by locally based medical professionals. If we are to learn from the response to the tsunami, it is essential that we seek long term sustainable and appropriate solutions and avoid the temptations of quick win ‘solutions’ that can sometimes be driven by well meaning, but misguided, intentions. The resources of the World bank, the UN and other international agencies are stretched to the full and only able to meet a portion of the basic needs for primary healthcare that we take for granted here in the West. We need to look for new ways of supporting those working tirelessly in hospitals and clinics to bring essential healthcare to those in desperate need, operating effectively with one hand tied behind their back. Hospitals, pharmaceutical companies and their employees hold one of the keys to help alleviate some of the pressure. However, we must be sure to seek long term, sustainable solutions that build up the local capacity. For more information please visit: www.hopeforgracekodindo.org and www.ihpuk.org Sincerely Anthony Dunnett CBE
Competing interests: None declared |
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Dr. Rajesh Chauhan, Consultant, Family Medicine & Communicable Diseases 309/9 A.V. Colony, Sikandra, Agra - 282007. India, Dr. Akhilesh Kumar Singh, MD; Dr. Parul Kushwah, MBBS, MISMCD; Sandeepa Chauhan; Shruti Chauhan.
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The editorial deals with a pertinent and perpetual problem [1] which should be taken up with equal earnest. For achieving ‘millennium development goals’, methods and modalities should be developed for developing nations by refurbishing, revamping and rejuvenating the health care infrastructure for the languishing population in deprived regions of Africa, and South-East Asian region, including India. Amongst the socio- economically deprived, an early age of marriage and pregnancy and thereafter incessant childbearing, breast feeding, etc, does takes it toll on a mother who barely manages all this without sufficient time or proper intervals to recoup her health. Malnutrition, pollution, poor hygiene and sanitation etc, compounds the adverse effects. Children born under such conditions are likewise deprived of better health and nutrition, right since inception, unlike their counterparts from the middle and upper socio -economic classes. Worse of all, resources generated and allocated for dealing with a specified population soon falls short, both in terms of quantity and quality, usually as a consequence of unrestrained population explosion, with every family usually having four to five children in its fold. Burgeoning population is probably one of the root causes for being unable to achieve the ‘millennium development goals’. For example, health facilities, food, other resources and facilities, meant for lets say 50 persons is soon expected to serve double that number or more. These figures just keep mounting, ultimately overwhelming the resources/facilities, causing disappointment and failure, which is easily avoidable by population control along with rejuvenation of the health care infrastructure. Family planning measures per say have not been able to produce desired results for the poor communities and the downtrodden, where they are needed the most. Ignorance, non-availability of timely guidance and help, desire to produce a male offspring, and often the need to get as many helping hands, which can be as early as when they are just 5 to 6 years old (by providing ‘nanny’ support to the younger siblings and 2 to 3 years later by helping their parent’s in their vocation or can go out to work for supplementation of the earnings), are perhaps the other leading causes of population explosion needing urgent attention. Health infrastructure for the poor and destitute needs overhauling and rejuvenation. Earmarked zones and teams may be formed, and reinforced if needed. Such teams can be entrusted with provision of maternal and child health care, dispensing free medicines, advertising benefits of family planning and small family norms, while also ensuring compliance of free health check-ups. Population control should be the emphasis. Pollution control, hygiene and sanitation, etc, can also be incorporated in their agenda. Additional properly motivated (and accountable) mobile medical teams can be employed to visit such areas which have a low health seeking pattern/behaviour. If possibly school education can be made compulsory (absolutely free, along with mid-day meals) for their children when they are five years old, it shall have two cherished outcomes. First and foremost, parents would probably then realize and take home the message that their children would no longer be able to supplement their earnings, unlike what is normally the present trend where most children of the low socio-economic class are sent off by their parents to earn at a tender age of 8 or 10 years at the most. Moreover the factor that their children would continue eating away into their earnings till they are mature enough and would also no longer be able to provide ‘nanny support’ to younger siblings left at home, will probably help push them voluntarily towards adopting family planning measures and make them more responsible. The second definite outcome would be of getting educated generation of the underprivileged as well, who can be a great asset for a community or a nation. They in turn would be our ‘second messengers’, and can help in achieving and sustaining the ‘millennium development goals’. With regards. Reference 1. Bhutta ZA. Bridging the equity gap in maternal and child health. BMJ 2005; 331: 585-586. Competing interests: None declared |
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Dr. Rajesh Chauhan, Consultant, Family Medicine, Communicable Diseases, Health & Hospital Administration 309/9 A.V. Colony, Sikandra, AGRA -282007, Dr. Akhilesh Kumar Singh, MD, Dr. Parul Kushwah, MBBS, MISMCD, Sandeepa Chauhan, Shruti Chauhan, and Shivendra Pratap Singh Chauhan.
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Dear Editor, It is the acceptance and the reverence of the BMJ which could affect a novel thinking to contain population growth so as to achieve millennium development goals. The path breaking suggestions that were sent as a rapid response on 01 Oct 2005, would have remained irrelevant and unnoticed, had it not been for the BMJ. Suddenly thereafter, after decades of pondering, compulsory education and banning of child labor has been adopted by India almost ten months later [1,2,3] as well as by Guyana [4]. Certainly it is the BMJ which has got some governments of developing countries into effecting a ban on child labor, initiating labor reforms, and making education compulsory for children up to 14 years of age. It goes without saying that the BMJ definitely brings about changes. Kudos to BMJ. Warm regards. Reference: (1) India: The Times of India: http://timesofindia.indiatimes.com/articleshow/1849466.cms (2) India: The Hindustan Times: http://www.hindustantimes.com/news/181_1761899,00300006.htm (3) India: The Hindu Business Line: http://www.thehindubusinessline.com/2006/08/03/stories/2006080300211000.htm (4) Guyana: Stabroek News: http://www.stabroeknews.com/index.pl/article_general_news?id=43311947 Competing interests: None declared |
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