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Rapid Responses: Rapid Responses published:
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Whose perspective - health provider or policy maker?
- Kelechi E. Nnoaham (12 November 2005)
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Getting the simple basics right in Maternal and Child Healthcare
- Michael I Carter (28 November 2005)
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Kelechi E. Nnoaham, Specialist Registrar in Public Health Department of Public Health, University of Oxford, Headington, Oxford OX3 7LF.
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Editor, the work by Evans et al is impressively well done with a very thorough methodology and exploration of the broader issues in health economic analyses. The use of a 'utility' or common outcome currency (DALY averted) however makes one wonder if this is a cost effectiveness or a cost-utility analysis. The authors note the imprecision of data on costs and outcomes and rightly include a simple sensitivity analysis. Public health interventions characteristically produce benefits, when they do, in the longer term. Consequently, cost and benefit discounting was done. It would have been appropriate to state the facts or assumptions underlying the choice of 3%, as even a slightly different value can be the difference between a cost- effective and cost-ineffective intervention. Ideally, a cost effectiveness analysis addresses issues of technical efficiency, which is most useful from the standpoint of a health care provider. Allocative efficiency, which on the other hand is more useful from a policy maker's perspective, might have been better addressed by a more robust consideration of other non-health interventions. For instance, one might rightly ask, 'is it probable that investment of finite resources in education might influence maternal mortality rates more effectively than investment in obstetric services?' A tool of greater macroeconomic usefulness would thus have been preferable. This is even made more important by the wider determinants of health being well known to transcend the immediate responsibilites and powers of public health. Generally, the opportunity for local adjustment of findings makes this well researched and thorough tool even more relevant to the pursuit of, at least, the health components of the millenium development goals. Competing interests: None declared |
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Michael I Carter, Consultant Anaesthetist Luton & Dunstable Hospital NHS Trust, Lewsey Road. Luton Beds. LU4 0DZ
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Dear Editor, Getting the simple basics right in Maternal and Child Healthcare. The BMJ of 12th November 2005 had three articles on some basic requirements for good Maternal and Child Healthcare in Africa and Asia (pp1107, 1133, 1137) During a two week charitable initiative to a Central Asian Capital this month, I was invited to give my views on the requirements for anaesthesia services in the regional and local maternity hospitals of the country. With three colleagues we looked at two maternity hospitals on the outskirts of the capital. In a country with a good power supply, the dependence on single oxygen cylinders to run hospital pipelines did not work well, and the attachments to the wall outlet points in the delivery suites caused problems. One outlet would need to be switched off to provide oxygen at another outlet in another part of the hospital. The real worth of a reliable oxygen source was seen in an oxygen concentrator in one neonatal room. The self-inflating resuscitation bags were of modern make but poor design. There were two oxygen inlets, one distal and the other proximal to the self-inflating bag. Oxygen added distally to the bag could then escape down the open, uncovered sidearm near to the patient. This design was present on both the adult and neonatal resuscitator bags. From my experience of using oxygen concentrators in Nepal and Bangladesh, I have no hesitation in recommending that these modern maintainable pieces of equipment are part of basic Maternal & Child Healthcare worldwide. The oxygen delivery systems for resuscitation need to be standardised and foolproof so that they cannot be assembled incorrectly or used with design faults. In any national service, provision needs to be made for the basics about oxygen delivery and requirement to be taught, and the equipment to be maintained. In this way, everyone’s future in maternal and child health will become more reliably secure. Yours sincerely Dr Michael Carter
Competing interests: None declared |
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