Geneva Health Forum Archive

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Economic Evaluation of Emergency and Surgical Disease in Developing Countries

Author(s): R. Y. Hsia*1, J. Razzak2, A. C. Tsai3
Affiliation(s): 1Department of Emergency Medicine, San Francisco General Hospital, University of California at San Francisco, USA, 2Emergency Medicine, Aga Khan University, Karachi, Pakistan, 3Department of Psychiatry, University of California at San Francisco, USA
Keywords: Burden of disease; emergency care; cost-effectiveness analysis; economic evaluation

Because public health has traditionally focused on prevention and primary care, emergency and surgical care has often been conceptualized as peripheral, costlier services that only well-developed and well-funded health systems are able to offer. However, there is emerging data showing that there are numerous treatable conditions within emergency and surgical care, such as road traffic injury that can significantly decrease morbidity and mortality of those in developing countries. Unfortunately, research activity correlates poorly with the injury burden in developing countries.


Because of the lack of work in this area, there are considerable methodological challenges specific to the evaluation of emergency and surgical services and interventions. Our research focuses on the definition of emergency and surgical care, as well as methodological advances in quantifying these conditions.


Defining what constitutes emergency care is the first task that must be undertaken before any measurements can be made. First, there must be recognition of the variety of presentations that present emergently. Emergency care obviously includes stabilization and treatment of injury-related illness and disease, such as road traffic accidents. Emergency care, however, extends beyond injury-related illness. It should be recognized that many in low-income and middle-income countries often do not seek care until a disease is in its later stages and thus may be prone to more emergent presentations. Consider the treatment of hernia, for example, while an efficient primary care system would, ideally, lessen the proportion of emergent presentations, conditions that require emergency and surgical care will always contribute significantly to a population’s disease burden, especially in countries with a high prevalence of unmet medical need. Treating those who present emergently (such as strangulation or incarceration, which if untreated could lead to severe morbidity and even mortality) would significantly reduce the morbidity and mortality of certain conditions and almost certainly be cost-effective. Clearly, the burden of emergency and surgical need extends beyond disease calculations themselves. Rather than population-based cross-sectional studies of presentations to an emergency ward, or creating a list of these ‘emergent’ entities and deriving calculations of incidence and prevalence, the method we propose consists of using existing burden of disease calculations and determining what percentage of them might present emergently. One could theoretically calculate what percentage of diabetes presents as diabetes ketoacidosis emergently, or malaria as cerebral malaria, or chronic obstructive pulmonary disease or asthma as acute respiratory distress. For example, one could calculate the annual burden of emergency obstetrical care based on knowledge that a minimum of 3-5% of all deliveries need emergency obstetric care to avoid mortality or severe morbidity.

Lessons learned:

We believe emergency and surgical care should be a priority of global health research and initiatives. An emphasis on the role of these services does not detract from current initiatives; indeed, many of Millennium Development Goals – e.g., cutting the maternal mortality ratio by three quarters between 1990 and 2015 – must be met by increasing access to emergency and surgical services. The focus on preventive health programmes in isolation from treating patients with urgent and emergent conditions who either die or live for the remainder of their lives with disabilities that are socially and economically costly to themselves and their families and to society must be revisited to compose a public health strategy that is comprehensive to include an understanding and appreciation of these issues.

Health Care Provision and Health Systems in the Immediate Phase of Mass Population Migration: Field Experience in Sri lanka

Author(s): l. dassanayake*1, A. Karunarathne2
Affiliation(s): 1Department of Orthopaedic Surgery Teaching Hospital Anuradhapura and Disaster prepairedness and resp, MInistry of Health, Colombo, 2Department of Neurosurgery, Teaching Hospital Anuradhapura, Anuradhapura, Sri Lanka
Keywords: Mass population migration, disaster, health

Provision of an optimum health care services determine the survival during disasters. Especially when the community had being on migration for a considerable time ,poor quality water, poor sanitation reduced food supplies and overcrowding may aggravate the health issues and demands for the health system to function on it’s full stretch. Scenario discussed will be the ground level experience of establishment of the health care system and provision of primary health care during the initial disaster phase in zone 4 of Menik farm relief villages with the sudden influx of 44,000 internally displaced population on the days of 15th and 16th of May 2009. This population had being on migration for months.


Identification and predicting the health issues of the community, assessing the capacity of the existing health facilities, prioritizing the services carried out before and on arrival of the IDP’s. First 24 hours spent on preventing the mortality among IDP’s by treating the life threatening conditions and launching the existing heath facility to its fullest extent. With the progress of the time services were expanded and consolidated. Special attentions were paid to health education,early detection and prevention of infectious outbreaks and strengthening the primary health care.Mobile health clinics were used to access the population in the peripheries of the zone until the proper primary health care centers are established. A Close coordination was established between the ground level and the central level to facilitate the smooth flow of logistics,human resources and enabling ground level to contribute efficiently in decision making.


A. Identification of the nature of health issue: On migration for a long period of time; Large number of unattended medical and surgical problems; Dehydration; Sub-optimal antenatal care compared to other areas; Came with epidemics of Hepatitis A, diarrhea and Chicken pox.
B. Identification of Main Issues in managing the health: A population with a very high morbidity; Limited man power; limited amount of logistics; Minimal infrastructure; Language barrier; Extreme stress in all levels of the staff; No emergency or disaster medicine physicians.
C. Prioritizing the Health services for the first day: Prevent deaths during the initial phase; Only life threatening conditions treated in first 24 hours; ORT to all patients with diarrhea under direct observation; Provision of bottled water with ORT to patients; Majority of the selected patients forresuscitation and treatments within first 24 hours were having diarrhea or severe chest infections; Provision of Water and food as a secondary objective.
D. Second Day: Started treating the other cases; Started collection of the vital demographic data; Finding volunteers from the community; Starting the antenatal clinics with mid wives; Starting nutritional center, feeding center, children’s clinic and health education programs.
E. By first week: Initiation of the EPI program; Start maintaining the health records; Acquisition of Mobile lab; Negotiating with NGO’s to expedite the construction of Primary Health Care Centers. Coordination of the resources and planning to provide a much comprehensive primary health care was started by the end of the first week.

The Challenges of Building Capacity: Nursing Education in Eritrea

Author(s): A. D. Ogbaghebriel*2, G. G. Yohannes2
Affiliation(s): 1Pharmacology, Asmara College of Health Sciences, Asmara, Eritrea, 2Nursing, Asmara College of Health Sciences, Asmara
Keywords: Nursing education, capacity building, Eritrea, specialized nurses, upgrading curriculum

Nurses provide the majority of health care services to the population of Eritrea. In some health facilities, nurses are the sole providers. For this reason, nurses are expected to play a major role in achieving the MDGs. Considering their vital role in the health care system, the government of Eritrea recognizes the need to enhance the nursing capacity through education. Nursing education in Eritrea dates back to 1955 conducted at junior and secondary levels of education. Currently all nursing education is conducted at post-secondary level.Education of nurses is directly linked to the competency of providing care. However, currently in Eritrea, regardless of level of training, all nurses have considerable responsibility for clinical decision making. Therefore, there is a need to better align education to responsibilities. Midwifery is a special issue in Eritrea’s nursing education, because most pre and post natal care as well as deliveries are done by nurse midwives.


Review of files of the School of Nursing of Asmara College of Health Sciences and data from Health Information System of the Eritrean Ministry of Health.


There is a demand for both increased numbers and nurses for higher responsibility in the Eritrean health care system. The demand for coverage is addressed by increasing class sizes, and that of higher level of responsibility by training specialized nurses with strong basic sciences base. The later also addresses the issue of career ladder in nursing. Major challenges in training include shortage of qualified instructors and large class sizes without proportional increase in resources. As solutions, upgrading faculty using innovative methods, and using innovative ways to access quality teaching materials electronically are implemented. Support systems are utilized to retain students through graduation. Nurses are trained along with other health workforce to foster better work relationships later. The use of innovative methods and responsive curricula are contributing greatly to the development of the nursing profession and the improvement of nursing services in Eritrea.

PMTCT: Uplifting Numbers from a Small District Hospital in Northern KwaZulu-Natal

Author(s): C. Burdet1
Affiliation(s): 1Outpatient Department, Manguzi Hospital, KwaNgwanase, South Africa
Keywords: PMTCT, Manguzi, KwaZulu-Natal, HIV, AIDS

PMTCT, Prevention of Mother to Child Transmission, is a combination of ante- and intrapartal antiretroviral drugs and general measures of precaution taken during and following childbirth so as to minimize the risk of vertical transmission of the HIV virus from an HIV infected mother to her child. Manguzi Hospital is a district hospital with 280 beds in Umkhanyakude health district of Norther KwaZulu-Natal, South Africa, serving a very rural population of an estimated 110 000 inhabitants. The HIV seroprevalence of mothers delivering in Manguzi Hospital’s maternity currently averages around 25%, and so properly conducted PMTCT is of crucial importance in this epdemiological context to minimize the number of children born with HIV at the very onset of life.


This article aims to describe the PMTCT programme as conducted in Manguzi Hospital. At 6 weeks of age, children exposed to the risk of contracting HIV are tested by blood PCR for HIV antigen positivity. The proportion of children who test positive at this stage is a reflection of the success of the antenatal and intrapartal portions of the PMTCT programme. Without any PMTCT measures, rate of transmission is estimated at up to 30%. Subsequent transmission can still occur via breastfeeding, with infection to a further 5-20% of children. The ultimate rate of mother-to-child transmission (as measured by VCT at 18 months in Manguzi) is therefore higher still than the 6-week PCR positivity rates.


The rate of mother-to-child transmission of HIV in Manguzi as measured by the 6-week PCR lies at 5.3%. The AZT coverage to mothers approaches 99%, and that to babies 75%. The percentage of qualifying HIV pregnant women initiated on HAART is 73%. The rate of mother-to-child transmission as compared to surrounding dictrict hospitals is low (8% average, ranging from 5.3% to 16.4% in surrounding Umkhanyakude district hospitals). As compared to the national performance of 12% transmission, this number appears to be low, but still lies slightly above the target of <5% transmission expected of a well functioning PMTCT programme as set out by South Africa’s National Strategic Plan for HIV and AIDS and STIs 2007-2011. With the South African health care system already straining under the burden of disease brought forth by the high HIV prevalence and the exodus of health care professionals, circumventing the mother-to-child transmission of HIV is a priority. Manguzi Hospital shows an example at a district level of a well conducted PMTCT programme.

Ethical Issues in Pandemic Preparedness

Author(s): A. A. Appiah1, P. L. Forson*1
Affiliation(s): 1Health, African Peace Network, Accra, Ghana

Ethical Issues in Pandemic Preparedness, Public Health Response, Rights, Welfare and Ideals, Transparency and Public Engagement, Resource constraints


Many of the conferences, meetings, and workshops convened in anticipation of a pandemic have focused on the specific strategies that can be used in fighting such a pandemic. The contributors to this abstract take a different tack and consider the creation of ethical guidelines for governments, health-care systems, and clinicians to be used in planning for and responding to a pandemic.


Many critical ethical issues arise in pan¬demic planning, preparedness and re¬sponse including:
1) priority access to medications, vaccines and intensive care unit beds, given the potential shortage of these essential resources;
2) obligations health-care workers have notwithstanding risks to their own health and the health of their families;
3) surveillance, isolation, quarantine and social-distancing measures to be undertaken in a way that respects ethical norms.
In order that response efforts in the event of a pandemic would be hastened, a publicly-discussed ethical framework is essential to maintain public trust, promote compliance, and minimize social disruption and economic loss. There is the need to assist social and political leaders at all levels who influence policy decisions about the incorporation of ethical considerations into national pandemic preparedness plans. Since specific decisions will depend on local circumstances and cultural values, it will be necessary to adapt global guidance to the regional and country-level context, with full respect to the principles and laws of international human rights. Public health measures that involve major costs should be reserved for situations where they can be reasonably expected to make a difference to the consequences of a pandemic. Preparedness planning for a pandemic involves balancing potentially conflicting individual and community interests. In emergency situations, the enjoyment of individual human rights and civil liberties may have to be limited in the public interest.


Public engagement and involvement of relevant stakeholders should be part of all aspects of planning. In order that public engagement in preparedness planning be meaningful, effective modes of communicating with and educating the public about the issues involved are essential. The principles of outbreak communication are: trust; transparency; communicating to the public early, dialogue with the public; and planning. Advance planning will allow the development of strategies that will reach the entire population and that are linguistically and culturally appropriate. While all countries must make reasonable efforts to prepare for a pandemic, differences in access to resources mean that what is reasonable for one country may not be reasonable for another. In developing countries, limited resources and immediate health-care needs may make it difficult to develop and implement comprehensive plans. In some cases, it may be possible to generate resources by using available funds more efficiently. The process for setting priorities and promoting equitable access involves civil society and other major stakeholders in the decision-making process so that decisions about the criteria to be used in allocating scarce resources are made in an open, transparent, and inclusive manner. Despite the criteria selected to govern the allocation of therapeutic and preventive measures, certain basics will be essential in all plans:
1) facilitating access to the highest level of treatment;
2) providing clinicians with clear and transparent screening and treatment protocols;
3) proposing prioritization criteria related to the maintenance of a functioning health-care system as needed in a crisis situation.

Developmental Medicine in Rural India at the Delta of Ganges

Author(s): S. Brahmochary1
Affiliation(s): 1Director, Indian Institute for Mother and Child, Kolkata, India
Keywords: Primary Health Care; Developmental Medicine; Rural India

Primary health care is a basic human right, as stated in the Alma Ata declaration. This reserves the right of every human being to get access to a healthy living and the availability of a standard health care system. Experience shows that 80% of medical problems in rural areas are very common and simple. They can be handled by basic medical care with the establishment of a primary health care system. Unfortunately, in remote areas like the Sundarbans area (West Bengal, India), no authority is interested in covering up the marginalized rural poor people. 80% to 90% of the people have no access to professional medical care. In these areas, 60% to 70% of the people are illiterate and have poor understanding of basic health and hygiene.


The Institute for Indian Mother and Child (IIMC) is a non-governmental voluntary organization, committed to promote child and maternal health, literacy and to accelerate international solidarity and peace. In 2003, IIMC started providing health services in Dhaki, a small village in a deep rural area in the Sundarbans. Within a few weeks, hundreds of people crowed the small outdoor clinic. The professional and modern health care brought big success in the area (currently, 1000 patients treated weekly). It was soon discovered that health and diseases are not the only problems -- there are other deep rooted issues which must be attended and taken care of: socio cultural problems, local believes, gender issues, illiteracy, poverty, etc. An approach that would rely solely on medical services would not solve the health problems of this community in the long run. Focus was first set on providing basic education to the children through building a school, but also on basic nutrition with the availability of a daily diet for pregnant women. A primary health center was built in Dhaki with secondary and tertiary health services, e.g. immunization, reproductive health care, maternal and child health, etc. Health education and promotion has been additionally performed through trained health workers that go directly in the surrounding villages. IIMC also set up a microfinance program (currently > 20’000 mother’s accounts). Recently, social justice and human right at the rural village level have been improved by the creation of local women’s support groups.


Health services in remote rural areas cannot be handled as a single isolated issue. In fact, health problems are much more than something we identify as the cause of a sickness. It should be seen as an expression of the social, educational and economical problems, which have to be solved by multilateral approaches. With the example of Dhaki, IIMC provides an example of a multilateral approach, combining medical services with education, microfinance, and social justice.

An E-Informed Senior Citizen: Health Information on the Net

Author(s): D. Srivastava*1, S. Diwakar2
Affiliation(s): 1Division of Publications and Information, 2Man Power Development, Indian Council of Medical Research, New Delhi, India
Keywords: Health Information, Elderly, Internet, Informed patient

While dream to live long is the legitimate right of every citizen, the social and economic implications and humanitarian issues of a growing population of elderly are causing serious concern and require immediate attention from the government and social organizations. In the age of INTERNET, the challenges for an informed senior citizen include literature on different health related problems specially for the elderly, treatment regimen, availability of new drugs, side effects and so on. The medical professionals and the Internet providers in India have never faced such challenges before. This unprecedented incident, heralds in a new era of the informed and e-ready patient. In the long run, this trend will translate into quality improvement and efficiency gains for the system. As we all know, the best way to improve quality and efficiency of the system is competition through informed consumer. In this respect, health literacy, digital divide, the readiness of health care providers and health care system, and the information infrastructure as a whole will be major challenges for policy makers.


In the present study, attempt has been made to analyze the hits on topics associated to elderly population from the web pages from India as well as rest of the world. To execute the above, endeavors have been made to explore the availability of information on “health problem” in the field of geriatrics or elderly population. Since the target group of web users were decided to be the elderly adults (not specifically research scientist) all the web pages from research journals or abstracting/indexing services have been excluded. Suggestions have been made to cover subject areas by these services. For collecting hits on world wide web pages search engine ‘Altavista’ as well as ‘Google’ was used. Same query was repeated for each year individually i.e. 1998, 1999, 2000, 2001 and 2002. Search results were randomly screened to collect ‘keywords’ related to diseases & problems of elderly population. A set of 25 keywords were identified. For detail analysis of ‘Pages from India, Boolean logic, ‘AND, OR, NOT’ were used to refine and pinpoint the results. Each and every entry in the list was systematically screened for (1) provision of health information, social, psychological (2) evaluated information likely to be accessed by the target population (3) the quality of information against certain criteria for example, by judging the authority of source, usefulness, readability or comprehensiveness of the provided information.


Disease based search revealed that general well being , in all the years was most favored, along with issue related to HIV/AIDS. (Except the year 2002). Other areas in context of world wide web were Neurological Problems & Alzheimer’s, Nutrition, Skin care. Pages dealing with Tuberculosis also showed an increasing trend. HIV/AIDS, Nutrition, General well being, Diabetes, Health & Hygiene, Alzheimers and Hypertension were the top most areas during all 5years together .Pages from India, revealed that they are concentrating upon few select problem areas like nutrition, (occupying the top most position in five years 51%), Rural population & health, diabetes, Population policy & old age, Hypertension and General well being. Some of the important areas like Neurological Problems, Urinary incontinence or Musculosleeletal issues has not been addressed adequately.

GHF2006 – LS02 – Access to Safe Healthcare

Session Outline

Lunch Session LS02, Friday, September 1 2006, 12:30-13:45
Chair(s): Didier Pittet, Switzerland, Liam Donaldson, UK
Patient Safety: A Global Challenge
Liam Donaldson, Chair of the WHO World Alliance for Patient Safety, Chief Medical Officer for England, UK 
The role of the Informed and Involved Patient in Access to Safe Healthcare: The Power of Partnerships
Susan Sheridan, Patient Safety, Consumers Advancing Patient Safety, Chicago, USA  
Access to Safe Care in Developing Countries
Stuart Whittaker, Research and Information, The Council for Health Service Accreditation of Southern Africa, Pinelands, South Africa 

Session Report

Contributors: Martin Elling (ICVolunteers), Marie Mac Gehee (ICVolunteers), Caroline Rheiner (ICVolunteers), Carissa Sahli (ICVolunteers)

The reality in many African countries is that patients may risk violence in hospitals, outdated x-ray machines, questionable hygienic standards. Image: Viola Krebs,

The speakers stressed the importance of concentrating on system failures rather than individual mistakes and errors. This involves the setting of standards and the development of systematic improvement programs that are complemented with constant performance monitoring. The experience of other high-risk industries such as the aviation industry highlights the importance of sustained action over the long term. The symposium also dwelt on the importance of involving consumers in the reduction of patient hazards.

Sir Liam Donaldson, Chair of the WHO World Alliance for Patient Safety and Chief Medical Officer for England, opened the symposium with a presentation that focused on the assertion that patient safety could be greatly improved. Sir Liam highlighted the importance of putting patient safety first and that the health sector could learn a lot from the experience of other high-risk industries such as the aviation or nuclear industries.

The airline industry, for example, has greatly improved safety by not merely dealing with individual (pilot) mistakes, but by concentrating on failures in the overall system. This requires a broad approach that includes transforming the culture, attitude, leadership and working practices of everybody involved in the industry. It also involves a much more systematic monitoring and constant training of the professionals active in the sector. In this respect he favorably compared the constant checking and training of pilots with the existing situation in the health care system. According to Sir Liam, the health sector, by following the approach of the airline industry, could greatly improve patient safety and significantly reduce the risk to patients.

However, even in countries that have sought to address this issue for years, progress is slow and further systematic efforts need to be made. Another issue concerns the balancing of patient safety against financial objectives and the regrettable lack of public accountability of health care professionals when patient safety issues are concerned.

Subsequently, Ms. Suzan E. Sheridan, of the Patient Safety, Consumers Advancing Patient Safety, Chicago, USA, spoke about the role of local community involvement in improving patient safety. Ms Sheridan's involvement in this topic comes from her own family's dramatic experience with two serious medical system failures. Such failures can often be prevented by assuring that health care consumers and their care takers are actively involved in treatments, i.e. patients should not have to solely rely on health professionals. Ms. Sheridan challenged health care providers, institutions, organizations and agencies to recognize and embrace the value and power of partnerships in reshaping the future of healthcare so that it is safe, compassionate and just. In this context Ms Sheridan gave a poignant example of health services consumers' involvement, P.I.C.K. (parents of infants and children with Kernicterus). This initiative started some years with only eight Moms and is now a national campaign.

The last speaker was Mr. S. Whittaker of the Council for Health Service Accreditation of Southern Africa (Cohsasa) who spoke from the perspective of developing countries. Mr. Whittaker recognized the reality in many African countries patients are at risk as they have to deal with violence in hospitals, outdated x-ray machines, questionable hygienic standards, etc. It is a paradox that although staff is often serious, patients are still frequently put at risk

Cohsasa seeks to improve the situation by implementing its Wedge Model. The Wedge Model has a double approach. On the one hand, it implements a standard quality improvement program that aims at improving facility, clinical, management, clinical and non-clinical support and technical systems. Although there is good support for this in the hospitals, Cohsasa finds that in the provinces, where one has to deal often with demoralized staff, progress is difficult. On the other hand, Cohsasa monitors adverse events that aim at identifying and improving systems failures that impact on patient safety, while they are being improved by the standard improvement arm.

This two-pronged approach permits serious system failures to be identified and interventions prioritized to ensure that patient safety is maximized.

GHF2006 – PL04 – A Critical View on the Role of Hospitals in Increasing Access to Health

Session outline

Plenary session, PL04, Thursday, August 31 2006, 18:00-19:30
Chair(s): Peter Saladin, Switzerland, Elisabeth Leforestier, France
Hospitals Promoting Access to Healthcare
Gillian Morgan, The NHS Confederation, London, United Kingdom 
Adeleke Olusegun Pitan, Honourable Commissioner for Education, Lagos State Ministry of Education, Lagos, Nigeria 
Redesigning Hospital Care to Meet the Needs of the Community
Wim Schellekens, Centre for Innovation and Development, Dutch Inspectorate, Leiderdorp, The Netherlands
Optimizing Hospitals in the Health Sector
Saleh Meky, Minister of Health, Eritrea 

Session Document

[Download not found]

Session report

Submitted by: Irene Amodei (ICVolunteers); Contributors: Melissa Bonnefin (ICVolunteers)

"Brain drain in health systems is a political issue". Image: Viola Krebs,

Hospitals have always played a pivotal role in the global healthcare system. They have power, authority and professional competences in both the rich and poor worlds. But what if we all begin to re-think the mission of hospital care and re-design the way we deliver it in order to increase access to health? The moment has arrived for reform in order to achieve optimal care, to learn from examples of real innovation and disseminate this knowledge, sharing ideas as well as best practices.

Mr. Adeleke Pitan, Honourable Commissioner for Education in Lagos' State Ministry of health from 1999 to 2006, began the plenary session with a detailed overview of the state of the health care delivery system in Nigeria and urban Africa. "Access to health has always been, and still remains, a problem in many urban areas" stated the former Minister, "due to uneven distribution of hospitals, inadequate health personnel, limited financial resources and weak motivation of the workforce". He then narrowed his focus criticizing the current inadequate knowledge and health education of the population (estimated at 150 million people) who still prefer alternative medicine practitioners. About 75% of Nigerian government hospitals are in urban areas and 25% in rural ones and on average 2.2 million patients are treated each year. The need to increase access to health has pushed the government to develop 'packages' to attract the elderly and most vulnerable groups; to introduce a number of free health services including free anti-natal care, free medical treatment for children aged between 0 and 12 years and for people over the age of 60. The Health Sector Reform programme also included free heart surgery for patients with heart defects, free eye treatment including surgery for cataracts and glaucoma and free breast cancer screening. Mr. Pitan described the opportunities that the reform offered such as Public-Private Partnership initiatives (PPP's),  the B-O-T system (build, operate and transfer), transfer of technology, training and re-training of health personnel. While the reform process has helped to assist the most vulnerable part of the population, trying to bring health to the doorstep of all citizens continues to be a major problem due to the small number of hospitals, shortage of specialist manpower, the lack of equipment and under-funding of the health care system.

'Reform' was also the key word of the presentation by the Minister of Health in Eritrea, Mr. Saleh Meky, who explained in detail the series of strategies adopted nationally in order to increase the cost-effectiveness of the health system and of its delivery services. "Change means new ways of thinking and acting", stated Mr. Meky, "and must be managed to ensure the result is a real improvement. Moreover, the quality of clinical services must not suffer during periods of rapid change". As a result of the concerted efforts made in Eritrea to build new health facilities and give them the necessary equipment and skilled health personnel, access to primary health care within 10 km from the health structures increased in the last years to around 70%. A good deal, given that 50% of the population lives within an area of 5 km.

Mr. Meky illustrated the main goals of the national reform, namely:

  • To ensure the equitable distribution of health services to rural and urban areas;
  • To strengthen Primary Health Care especially in remote and inaccessible areas;
  • Actively to promote the dissemination of accurate information on health practices;
  • To use a strong evidence-based decision-making process.

According to Mr. Meky, the basic principles of any health system reform are the improvement of management (namely the Health Management Information System, HR management, quality and financial management) and the decentralization of functions "to that level where optimum value can be attained". A country in transformation, like Eritrea, has to deal with additional challenges, for example the urgent need to control both tropical (historical) and 'rich-countries' (new to Eritrea) diseases. For that reason, the decentralization process is often not easily manageable. As a solution Mr. Meky introduced the concept of "hospital autonomy", an alternative method of organizing and financing health care services. Hospital autonomy could also be seen as an effective merge of the best elements of the public and private sectors; a kind of parastatal hospital that works in a private way from the point of view of finance and bureaucratic reduction, which when properly implemented, enhances effectiveness and efficiency.

Mr. Meky ended his presentation by stressing the need for stronger community involvement as the only way to overcome the always present danger of brain drain. "Brain drain in health systems is a political issue" stated the Minister. "If we want to have some chance to stop it we must provide a comfortable ecological and financial environment, to train as many people as possible, to appeal to people's nationalism and, most importantly, to make people think that they really are the owners of their hospitals".

Mr. Wim Schellekens, CEO of the Center for Innovation and Development in The Netherlands, offered the plenary a mostly self-critical 'first-world' point of view. "How effective and safe is hospital care?" questioned Mr. Schellekens, "How to do a better job?".

Despite the progress of medical science, we still see a huge amount of errors in the way we deliver care (overuse, under use or misuse of drugs), in the way we organize care (coordination problems and delays) and in the way we take care (absence of transparency, empathy and patient-involvement). In the USA, there are 44,000 to 98,000 deaths in hospitals each year (8th-3rd cause of death) and there is no correlation between cost and mortality. Care for patients should be safe, effective, patient-centred, timely and efficient, with equity for all. Patients, of course, do not expect needless deaths, needless pain, unwanted waits and helplessness. In short, quality is the big issue. To support his claims Mr. Schellekens described the successful IHI Boston experience in 2004, which, with six simple interventions (like the creation of a Rapid Response Team), resulted in 122,300 lives saved in the 3,000 hospitals involved. The key to success is to have vision, a strategy and leadership ("First study, then act; first plan then do!"). The theory affirms that when we have convinced 20% of our target, the rest will automatically follow. In The Netherlands the "Better Faster" programme, that aimed to get breakthrough results in 20 % of Dutch hospitals in four years, succeeded by acting at four levels of intervention: system level, institutional level, level of care-process and patient level. According to Mr. Schellekens the mission of hospitals has shifted from "delivering specialized care to our patients" to "responsibility for the care in our region" to "promote health to all our citizens".

Redesigning Hospital Care to Meet the Needs of the Community

Author(s): Wim Schellekens1
Affiliation(s): 1Centre for Innovation and Development, Dutch Inspectorate, Leiderdorp, The Netherlands
Key issues: Hospitals are an essential part of our healthcare system. In hospitals we see the progress of medical science. But how content can we be with the current status of our hospitals? What are the main issues in hospital care in most developed countries? Wherever we measure, we see a huge variation in the way care is offered and organised. We harm patients by the way we deliver and organize care which results in unnecessary suffering and even death. We have compartmentalized our care between disciplines, departments and institutions. Our care is too much doctor/organisation-centred instead of patient-centred. There is a wall between public health and our cure-system. Hospital care takes almost all our healthcare money, but what is the costeffectiveness ratio? In many places we see remarkable improvements and examples of real innovations of care. But what about implementation of this knowledge and dissemination of these best practices? What we need is interventions on four different levels: 1) Patient level: patients can be the main driving force for innovation and improvement; 2) Process level: here we need the innovation and improvement; 3) Organisational level: leadership, organisational support, redesign of the support processes, HRM and IT; 4) Level of the health care system: how about the financial incentives, the healthcare insurance system, the legal issues, etc.? Let me focus on some fundamental issues for innovation and change: 1. Leadership: I have seen a shift in the mission of hospitals: from delivering specialised care to patients, to responsibility for the healthcare in our region, to responsible to improve health in our region. Leaders are responsible for the level of ambition. They translate mission and vision into strategy and operational goals, and they are able to develop and apply a strategy for implementation and spread. They make the link between quality and finance. 2. A strategy to improve quality and safety: We need a quality-system, multidisciplinary cross-functional and cross-organisational collaboration, a framework of methods and tools, training, and a strategy for implementation and spread. 3. Involvement of patients: We have not so much experience in involvement of patients in our daily care-delivery or our improvement efforts. This will bring us to a new level of performance. 4. Specialisation and stratification of care: Quality results depend on the experience of the care team. It becomes a necessity to concentrate high-tech care and the care for rare diseases in centres of excellence and to focus on high quality standardized care for the common diseases and low/medium-tech care in our regular hospitals: a vertical integrated system. At the same time it shows that we can get much better results if we stratify our care in acute, elective and chronic care. 5. Outreach to public health: The knowledge and experience of hospital workers should be applied in public health primary prevention, immunisation programs, screening for early detection of diseases, self-help of patients and patient-groups, public information, etc. There still is a big gap between health care and social care, education, welfare, living, etc.
Conclusion (max 400 words): Rethinking the mission of hospital care and redesigning the way we deliver hospital care is urgent. It is the task of leaders in this field to take up the challenge.