• Evaluating Niger's experience in strengthening supervision, improving availability of child survival drugs through cost recovery, and initiating training for Integrated Management of Childhood Illness (IMCI)

      Legros Stephane; Tawfik Youssef; Geslin Colette (BioMed Central, 2001)
      <p>Abstract</p> <p>Background</p> <p>WHO and UNICEF have recently developed the "Integrated Management of Childhood Illness" (IMCI) as an efficient strategy to assist developing countries reduce childhood mortality. Early experience with IMCI implementation suggests that clinical training is essential but not sufficient for the success of the strategy. Attention needs to be given to strengthening health systems, such as supervision and drug supply.</p> <p>Results</p> <p>This paper presents results of evaluating an innovative approach for implementing IMCI in Niger. It starts with strengthening district level supervision and improving the availability of child survival drugs through cost recovery well before the beginning of IMCI clinical training. The evaluation documented the effectiveness of the initial IMCI clinical training and referral.</p> <p>Conclusions</p> <p>Strengthening supervision and assuring the availability of essential drugs need to precede the initiation of IMCI Clinical training. Longer term follow up is necessary to confirm the impact of the approach on IMCI preparation and implementation.</p>
    • Evaluating Niger's experience in strengthening supervision, improving availability of child survival drugs through cost recovery, and initiating training for Integrated Management of Childhood Illness (IMCI)

      Legros Stephane; Tawfik Youssef M; Geslin Colette (BioMed Central, 2001-07-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;WHO and UNICEF have recently developed the "Integrated Management of Childhood Illness" (IMCI) as an efficient strategy to assist developing countries reduce childhood mortality. Early experience with IMCI implementation suggests that clinical training is essential but not sufficient for the success of the strategy. Attention needs to be given to strengthening health systems, such as supervision and drug supply.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;This paper presents results of evaluating an innovative approach for implementing IMCI in Niger. It starts with strengthening district level supervision and improving the availability of child survival drugs through cost recovery well before the beginning of IMCI clinical training. The evaluation documented the effectiveness of the initial IMCI clinical training and referral.&lt;/p&gt; &lt;p&gt;Conclusions&lt;/p&gt; &lt;p&gt;Strengthening supervision and assuring the availability of essential drugs need to precede the initiation of IMCI Clinical training. Longer term follow up is necessary to confirm the impact of the approach on IMCI preparation and implementation.&lt;/p&gt;
    • Paediatric referrals in rural Tanzania: the Kilombero District Study &#8211; a case series

      Menendez Clara; Schellenberg Joanna; Alonso Pedro; Font Fidel; Quinto Llorens; Masanja Honoraty; Tanner Marcel; Ascaso Carlos; Nathan Rose (BioMed Central, 2002)
      <p>Abstract</p> <p>Background</p> <p>Referral is a critical part of appropriate primary care and of the Integrated Management of Childhood Illness (IMCI) strategy. We set out to study referrals from the aspect both of primary level facilities and the referral hospital in Kilombero District, southern Tanzania. Through record review and a separate prospective study we estimate referral rates, report on delays in reaching referral care and summarise the appropriateness of pediatric referral cases in terms of admission to the pediatric ward at a district hospital</p> <p>Methods</p> <p>A sample of patient records from primary level government health facilities throughout 1993 were summarised by age, diagnosis, whether a new case or a reattendance, and whether or not they were referred. From August 1994 to July 1995, mothers or carers of all sick children less than five years old attending the Maternal and Child Health (MCH) clinic or outpatient department (OPD) of SFDDH were interviewed using a standard questionnaire recording age, sex, diagnosis, place of residence, whether the child was admitted to the paediatric ward, and whether the child was referred.</p> <p>Results</p> <p>From record review, only 0.6% of children from primary level government facilities were referred to a higher level of care. At the referral hospital, 7.8 cases per thousand under five catchment population had been referred annually. The hospital MCH clinic and OPD were generally used by children who lived nearby: 91% (n = 7,166) of sick children and 75% (n = 607) of admissions came from within 10 km. Of 235 referred children, the majority (62%) had come from dispensaries. Almost half of the referrals (48%) took 2 or more days to arrive at the hospital. Severe malaria and anaemia were the leading diagnoses in referred children, together accounting for a total of 70% of all the referrals. Most referred children (167/235, 71%) were admitted to the hospital paediatric ward.</p> <p>Conclusions</p> <p>The high admission rate among referrals suggests that the decision to refer is generally appropriate, but the low referral rate suggests that too few children are referred. Our findings suggest that the IMCI strategy may need to be adapted in sparsely-populated areas with limited transport, so that more children may be managed at peripheral level and fewer children need referral.</p>
    • Cross-sectional study of morbidity, morbidity-associated factors and cost of treatment in Ngaoundere, Cameroon, with implications for health policy in developing countries and development assistance policy

      Hurum Harald; Holtedahl Knut (BioMed Central, 2002)
      <p>Abstract</p> <p>Background</p> <p>In a population-based epidemiological study in Ngaoundere, Cameroon, we studied cross-sectional child morbidity and the cost of necessary investigation and treatment.</p> <p>Methods</p> <p>Three teams of two to three health workers visited haphazardly selected households in all major housing quarters. We asked permission to enter for a health survey. Children with cough, fever or weight loss as well as sick adults were offered free-of-charge local hospital examination and treatment.</p> <p>Results</p> <p>From 177 households with 1777 persons, 51 (2.9%) persons were referred. Thirty-five of them had an undiagnosed disease threatening individual health and in many cases also public health. Seven were hospitalised, including three adults with tuberculosis. Malnutrition was diagnosed in nine small children. Four patients had AIDS, seven had malaria. Average total cost for ambulant patients was 15 USD, for hospitalised patients 110 USD.</p> <p>In the households, almost half of the women 16&#8211;50 years of age had no schooling. Two per cent of women and nine per cent of men were daily smokers. Coughing children were more likely than non-coughing children to live in a household with at least one smoker (OR = 3.58, 95% CI 1.72 to 7.46), and they generally lived in more poor households (P = 0.018). Twelve of 16 children with weight loss were referred from households with a high poverty score.</p> <p>Conclusions</p> <p>Adult smoking and poverty affect children's health. The cost of hospitalisation or long-lasting therapy is beyond the means of most ordinary families. Diseases with severe consequences for public health, like tuberculosis, AIDS and malaria should have national programs with free, decentralised examination and treatment. Access to generic drugs is important. A major educational effort is needed to improve public health.</p>
    • Community based rehabilitation: a strategy for peace-building

      Koros Michael; Boyce William; Hodgson Jennifer (BioMed Central, 2002)
      <p>Abstract</p> <p>Background</p> <p>Certain features of peace-building distinguish it from peacekeeping, and make it an appropriate strategy in dealing with vertical conflict and low intensity conflict. However, some theorists suggest that attempts, through peace-building, to impose liberal values upon non-democratic cultures are misguided and lack an ethical basis.</p> <p>Discussion</p> <p>We have been investigating the peace-building properties of community based approaches to disability in a number of countries. This paper describes the practice and impact of peace-building through Community Based Rehabilitation (CBR) strategies in the context of armed conflict. The ethical basis for peace-building through practical community initiatives is explored. A number of benefits and challenges to using CBR strategies for peace-building purposes are identified.</p> <p>Summary</p> <p>During post-conflict reconstruction, disability is a powerful emotive lever that can be used to mobilize cooperation between factions. We suggest that civil society, in contrast to state-level intervention, has a valuable role in reducing the risks of conflict through community initiatives.</p>
    • Human rights in the biotechnology era 1

      Benatar Solomon (BioMed Central, 2002)
      <p>Abstract</p> <p>Backgound</p> <p>The concept of Human Rights has become the modern civilising standard to which all should aspire and indeed attain.</p> <p>Discussion</p> <p>In an era characterised by widening disparities in health and human rights across the world and spectacular advances in biotechnology it is necessary to reflect on the extent to which human rights considerations are selectively applied for the benefit of the most privileged people. Attention is drawn particularly to sub-Saharan Africa as a marginalised region at risk of further marginalisation if the power associated with the new biotechnology is not used more wisely than power has been used in the past. To rectify such deficiencies it is proposed that the moral agenda should be broadened and at the very least the concept of rights should be more closely integrated with duties</p> <p>Summary</p> <p>New forms of power being unleashed by biotechnology will have to be harnessed and used with greater wisdom than power has been used in the past. Widening disparities in the world are unlikely to be diminished merely by appealing to human rights. We recommend that a deeper understanding is required of the underlying causes of such disparities and that the moral discourse should be extended beyond human rights language.</p>
    • Policy mapping for establishing a national emergency health policy for Nigeria

      Aliyu Zakari (BioMed Central, 2002)
      <p>Abstract</p> <p>Background</p> <p>The number of potential life years lost due to accidents and injuries though poorly studied has resulted in tremendous economic and social loss to Nigeria. Numerous socio-cultural, economic and political factors including the current epidemic of ethnic and religious conflicts act in concert in predisposing to and enabling the ongoing catastrophe of accident and injuries in Nigeria.</p> <p>Methods</p> <p>Using the "policymaker", Microsoft-Windows<sup>®</sup> based software, the information generated on accidents and injuries and emergency health care in Nigeria from literature review, content analysis of relevant documents, expert interviewing and consensus opinion, a model National Emergency Health Policy was designed and analyzed. A major point of analysis for the policy is the current political feasibility of the policy including its opportunities and obstacles in the country.</p> <p>Results</p> <p>A model National Emergency Health Policy with policy goals, objectives, programs and evaluation benchmarks was generated. Critical analyses of potential policy problems, associated multiple players, diverging interests and implementation guidelines were developed.</p> <p>Conclusions</p> <p>"Political health modeling" a term proposed here would be invaluable to policy makers and scholars in developing countries in assessing the political feasibility of policy managing. Political modeling applied to the development of a NEHP in Nigeria would empower policy makers and the policy making process and would ensure a sustainable emergency health policy in Nigeria.</p>
    • High-tech and low-tech orthopaedic surgery in Sub-Saharan Africa

      Kluge Wolfram; Bauer Heike (BioMed Central, 2002)
      <p>Abstract</p> <p>Background</p> <p>Zambia's governmental health system suffers from shortage of surgical supplies and poor management skills for the sparse resources at hand. The situation has been worsened by the dual epidemics of HIV disease and tuberculosis. On the other hand the private medical sector has benefited greatly from less bureaucracy under the goverment of the Movement for Multi-party Democracy.</p> <p>Discussion</p> <p>The Zambian-Italian Orthopaedic Hospital in Lusaka is a well organized small unit providing free treatment of physically disabled children. The running costs are met from the fees charged for private consultations, supplemented by donations. State of the art surgical techniques are being used for congenital and acquired musculo-skeletal abnormalities. Last year 513 patients were operated upon free of charge and 320 operations were performed on private patients.</p>
    • High-tech and low-tech orthopaedic surgery in Sub-Saharan Africa

      Bauer Heike I; Kluge Wolfram H (BioMed Central, 2002-02-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Zambia's governmental health system suffers from shortage of surgical supplies and poor management skills for the sparse resources at hand. The situation has been worsened by the dual epidemics of HIV disease and tuberculosis. On the other hand the private medical sector has benefited greatly from less bureaucracy under the goverment of the Movement for Multi-party Democracy.&lt;/p&gt; &lt;p&gt;Discussion&lt;/p&gt; &lt;p&gt;The Zambian-Italian Orthopaedic Hospital in Lusaka is a well organized small unit providing free treatment of physically disabled children. The running costs are met from the fees charged for private consultations, supplemented by donations. State of the art surgical techniques are being used for congenital and acquired musculo-skeletal abnormalities. Last year 513 patients were operated upon free of charge and 320 operations were performed on private patients.&lt;/p&gt;
    • Paediatric referrals in rural Tanzania: the Kilombero District Study – a case series

      Menendez Clara; Ascaso Carlos; Nathan Rose; Masanja Honoraty; Quinto Llorens; Font Fidel; Tanner Marcel; Schellenberg Joanna; Alonso Pedro (BioMed Central, 2002-04-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Referral is a critical part of appropriate primary care and of the Integrated Management of Childhood Illness (IMCI) strategy. We set out to study referrals from the aspect both of primary level facilities and the referral hospital in Kilombero District, southern Tanzania. Through record review and a separate prospective study we estimate referral rates, report on delays in reaching referral care and summarise the appropriateness of pediatric referral cases in terms of admission to the pediatric ward at a district hospital&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;A sample of patient records from primary level government health facilities throughout 1993 were summarised by age, diagnosis, whether a new case or a reattendance, and whether or not they were referred. From August 1994 to July 1995, mothers or carers of all sick children less than five years old attending the Maternal and Child Health (MCH) clinic or outpatient department (OPD) of SFDDH were interviewed using a standard questionnaire recording age, sex, diagnosis, place of residence, whether the child was admitted to the paediatric ward, and whether the child was referred.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;From record review, only 0.6% of children from primary level government facilities were referred to a higher level of care. At the referral hospital, 7.8 cases per thousand under five catchment population had been referred annually. The hospital MCH clinic and OPD were generally used by children who lived nearby: 91% (n = 7,166) of sick children and 75% (n = 607) of admissions came from within 10 km. Of 235 referred children, the majority (62%) had come from dispensaries. Almost half of the referrals (48%) took 2 or more days to arrive at the hospital. Severe malaria and anaemia were the leading diagnoses in referred children, together accounting for a total of 70% of all the referrals. Most referred children (167/235, 71%) were admitted to the hospital paediatric ward.&lt;/p&gt; &lt;p&gt;Conclusions&lt;/p&gt; &lt;p&gt;The high admission rate among referrals suggests that the decision to refer is generally appropriate, but the low referral rate suggests that too few children are referred. Our findings suggest that the IMCI strategy may need to be adapted in sparsely-populated areas with limited transport, so that more children may be managed at peripheral level and fewer children need referral.&lt;/p&gt;
    • Human rights in the biotechnology era 1

      Benatar Solomon R (BioMed Central, 2002-04-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Backgound&lt;/p&gt; &lt;p&gt;The concept of Human Rights has become the modern civilising standard to which all should aspire and indeed attain.&lt;/p&gt; &lt;p&gt;Discussion&lt;/p&gt; &lt;p&gt;In an era characterised by widening disparities in health and human rights across the world and spectacular advances in biotechnology it is necessary to reflect on the extent to which human rights considerations are selectively applied for the benefit of the most privileged people. Attention is drawn particularly to sub-Saharan Africa as a marginalised region at risk of further marginalisation if the power associated with the new biotechnology is not used more wisely than power has been used in the past. To rectify such deficiencies it is proposed that the moral agenda should be broadened and at the very least the concept of rights should be more closely integrated with duties&lt;/p&gt; &lt;p&gt;Summary&lt;/p&gt; &lt;p&gt;New forms of power being unleashed by biotechnology will have to be harnessed and used with greater wisdom than power has been used in the past. Widening disparities in the world are unlikely to be diminished merely by appealing to human rights. We recommend that a deeper understanding is required of the underlying causes of such disparities and that the moral discourse should be extended beyond human rights language.&lt;/p&gt;
    • Cross-sectional study of morbidity, morbidity-associated factors and cost of treatment in Ngaoundere, Cameroon, with implications for health policy in developing countries and development assistance policy

      Holtedahl Knut; Hurum Harald (BioMed Central, 2002-04-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;In a population-based epidemiological study in Ngaoundere, Cameroon, we studied cross-sectional child morbidity and the cost of necessary investigation and treatment.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;Three teams of two to three health workers visited haphazardly selected households in all major housing quarters. We asked permission to enter for a health survey. Children with cough, fever or weight loss as well as sick adults were offered free-of-charge local hospital examination and treatment.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;From 177 households with 1777 persons, 51 (2.9%) persons were referred. Thirty-five of them had an undiagnosed disease threatening individual health and in many cases also public health. Seven were hospitalised, including three adults with tuberculosis. Malnutrition was diagnosed in nine small children. Four patients had AIDS, seven had malaria. Average total cost for ambulant patients was 15 USD, for hospitalised patients 110 USD.&lt;/p&gt; &lt;p&gt;In the households, almost half of the women 16–50 years of age had no schooling. Two per cent of women and nine per cent of men were daily smokers. Coughing children were more likely than non-coughing children to live in a household with at least one smoker (OR = 3.58, 95% CI 1.72 to 7.46), and they generally lived in more poor households (P = 0.018). Twelve of 16 children with weight loss were referred from households with a high poverty score.&lt;/p&gt; &lt;p&gt;Conclusions&lt;/p&gt; &lt;p&gt;Adult smoking and poverty affect children's health. The cost of hospitalisation or long-lasting therapy is beyond the means of most ordinary families. Diseases with severe consequences for public health, like tuberculosis, AIDS and malaria should have national programs with free, decentralised examination and treatment. Access to generic drugs is important. A major educational effort is needed to improve public health.&lt;/p&gt;
    • Policy mapping for establishing a national emergency health policy for Nigeria

      Aliyu Zakari Y (BioMed Central, 2002-08-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;The number of potential life years lost due to accidents and injuries though poorly studied has resulted in tremendous economic and social loss to Nigeria. Numerous socio-cultural, economic and political factors including the current epidemic of ethnic and religious conflicts act in concert in predisposing to and enabling the ongoing catastrophe of accident and injuries in Nigeria.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;Using the "policymaker", Microsoft-Windows&lt;sup&gt;®&lt;/sup&gt; based software, the information generated on accidents and injuries and emergency health care in Nigeria from literature review, content analysis of relevant documents, expert interviewing and consensus opinion, a model National Emergency Health Policy was designed and analyzed. A major point of analysis for the policy is the current political feasibility of the policy including its opportunities and obstacles in the country.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;A model National Emergency Health Policy with policy goals, objectives, programs and evaluation benchmarks was generated. Critical analyses of potential policy problems, associated multiple players, diverging interests and implementation guidelines were developed.&lt;/p&gt; &lt;p&gt;Conclusions&lt;/p&gt; &lt;p&gt;"Political health modeling" a term proposed here would be invaluable to policy makers and scholars in developing countries in assessing the political feasibility of policy managing. Political modeling applied to the development of a NEHP in Nigeria would empower policy makers and the policy making process and would ensure a sustainable emergency health policy in Nigeria.&lt;/p&gt;
    • Community based rehabilitation: a strategy for peace-building

      Hodgson Jennifer; Koros Michael; Boyce William (BioMed Central, 2002-11-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Certain features of peace-building distinguish it from peacekeeping, and make it an appropriate strategy in dealing with vertical conflict and low intensity conflict. However, some theorists suggest that attempts, through peace-building, to impose liberal values upon non-democratic cultures are misguided and lack an ethical basis.&lt;/p&gt; &lt;p&gt;Discussion&lt;/p&gt; &lt;p&gt;We have been investigating the peace-building properties of community based approaches to disability in a number of countries. This paper describes the practice and impact of peace-building through Community Based Rehabilitation (CBR) strategies in the context of armed conflict. The ethical basis for peace-building through practical community initiatives is explored. A number of benefits and challenges to using CBR strategies for peace-building purposes are identified.&lt;/p&gt; &lt;p&gt;Summary&lt;/p&gt; &lt;p&gt;During post-conflict reconstruction, disability is a powerful emotive lever that can be used to mobilize cooperation between factions. We suggest that civil society, in contrast to state-level intervention, has a valuable role in reducing the risks of conflict through community initiatives.&lt;/p&gt;
    • Global plagues and the Global Fund: Challenges in the fight against HIV, TB and malaria

      Tan Darrell; Ford Nathan; Upshur Ross (BioMed Central, 2003)
      <p>Abstract</p> <p>Background</p> <p>Although a grossly disproportionate burden of disease from HIV/AIDS, TB and malaria remains in the Global South, these infectious diseases have finally risen to the top of the international agenda in recent years. Ideal strategies for combating these diseases must balance the advantages and disadvantages of 'vertical' disease control programs and 'horizontal' capacity-building approaches.</p> <p>Discussion</p> <p>The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) represents an important step forward in the struggle against these pathogens. While its goals are laudable, significant barriers persist. Most significant is the pitiful lack of funds committed by world governments, particularly those of the very G8 countries whose discussions gave rise to the Fund. A drastic scaling up of resources is the first clear requirement for the GFATM to live up to the international community's lofty intentions. A directly related issue is that of maintaining a strong commitment to the treatment of the three diseases along with traditional prevention approaches, with the ensuing debates over providing affordable access to medications in the face of the pharmaceutical industry's vigorous protection of patent rights.</p> <p>Summary</p> <p>At this early point in the Fund's history, it remains to be seen how these issues will be resolved at the programming level. Nevertheless, it is clear that significant structural changes are required in such domains as global spending priorities, debt relief, trade policy, and corporate responsibility. HIV/AIDS, tuberculosis and malaria are global problems borne of gross socioeconomic inequality, and their solutions require correspondingly geopolitical solutions.</p>
    • An Australian Aboriginal birth cohort: a unique resource for a life course study of an Indigenous population. A study protocol

      Reid Alison; Singh Gurmeet; Bucens Ingrid; Sayers Susan; Flynn Kathryn; Mackerras Dorothy (BioMed Central, 2003)
      <p>Abstract</p> <p>Background</p> <p>The global rise of Type 2 diabetes and its complications has drawn attention to the burden of non-communicable diseases on populations undergoing epidemiological transition. The life course approach of a birth cohort has the potential to increase our understanding of the development of these chronic diseases. In 1987 we sought to establish an Australian Indigenous birth cohort to be used as a resource for descriptive and analytical studies with particular attention on non-communicable diseases. The focus of this report is the methodology of recruiting and following-up an Aboriginal birth cohort of mobile subjects belonging to diverse cultural and language groups living in a large sparsely populated area in the Top End of the Northern Territory of Australia.</p> <p>Methods</p> <p>A prospective longitudinal study of Aboriginal singletons born at the Royal Darwin Hospital 1987&#8211;1990, with second wave cross-sectional follow-up examination of subjects 1998&#8211;2001 in over 70 different locations. A multiphase protocol was used to locate and collect data on 686 subjects with different approaches for urban and rural children. Manual chart audits, faxes to remote communities, death registries and a full time subject locator with past experience of Aboriginal communities were all used.</p> <p>Discussion</p> <p>The successful recruitment of 686 Indigenous subjects followed up 14 years later with vital status determined for 95% of subjects and examination of 86% shows an Indigenous birth cohort can be established in an environment with geographic, cultural and climatic challenges. The high rates of recruitment and follow up indicate there were effective strategies of follow-up in a supportive population.</p>
    • Care for perinatal illness in rural Nepal: a descriptive study with cross-sectional and qualitative components

      Manandhar Madan; Mesko Natasha; Manandhar Dharma; Standing Hilary; Osrin David; Costello Anthony; Tamang Suresh; Shrestha Bhim (BioMed Central, 2003)
      <p>Abstract</p> <p>Background</p> <p>Maternal, perinatal and neonatal mortality rates remain high in rural areas of developing countries. Most deliveries take place at home and care-seeking behaviour is often delayed. We report on a combined quantitative and qualitative study of care seeking obstacles and practices relating to perinatal illness in rural Makwanpur district, Nepal, with particular emphasis on consultation strategies.</p> <p>Methods</p> <p>The analysis included a survey of 8798 women who reported a birth in the previous two years [of whom 3557 reported illness in their pregnancy], on 30 case studies of perinatal morbidity and mortality, and on 43 focus group discussions with mothers, other family members and health workers.</p> <p>Results</p> <p>Early pregnancy was often concealed, preparation for birth was minimal and trained attendance at birth was uncommon. Family members were favoured attendants, particularly mothers-in-law. The most common recalled maternal complications were prolonged labour, postpartum haemorrhage and retained placenta. Neonatal death, though less definable, was often associated with cessation of suckling and shortness of breath. Many home-based care practices for maternal and neonatal illness were described. Self-medication was common.</p> <p>There were delays in recognising and acting on danger signs, and in seeking care beyond the household, in which the cultural requirement for maternal seclusion, and the perceived expense of care, played a part. Of the 760 women who sought care at a government facility, 70% took more than 12 hours from the decision to seek help to actual consultation. Consultation was primarily with traditional healers, who were key actors in the ascription of causation. Use of the government primary health care system was limited: the most common source of allopathic care was the district hospital.</p> <p>Conclusions</p> <p>Major obstacles to seeking care were: a limited capacity to recognise danger signs; the need to watch and wait; and an overwhelming preference to treat illness within the community. Safer motherhood and newborn care programmes in rural communities, must address both community and health facility care to have an impact on morbidity and mortality. The roles of community actors such as mothers-in-law, husbands, local healers and pharmacies, and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened.</p>
    • An Australian Aboriginal birth cohort: a unique resource for a life course study of an Indigenous population. A study protocol

      Flynn Kathryn; Bucens Ingrid; Singh Gurmeet; Mackerras Dorothy; Sayers Susan M; Reid Alison (BioMed Central, 2003-03-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;The global rise of Type 2 diabetes and its complications has drawn attention to the burden of non-communicable diseases on populations undergoing epidemiological transition. The life course approach of a birth cohort has the potential to increase our understanding of the development of these chronic diseases. In 1987 we sought to establish an Australian Indigenous birth cohort to be used as a resource for descriptive and analytical studies with particular attention on non-communicable diseases. The focus of this report is the methodology of recruiting and following-up an Aboriginal birth cohort of mobile subjects belonging to diverse cultural and language groups living in a large sparsely populated area in the Top End of the Northern Territory of Australia.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;A prospective longitudinal study of Aboriginal singletons born at the Royal Darwin Hospital 1987–1990, with second wave cross-sectional follow-up examination of subjects 1998–2001 in over 70 different locations. A multiphase protocol was used to locate and collect data on 686 subjects with different approaches for urban and rural children. Manual chart audits, faxes to remote communities, death registries and a full time subject locator with past experience of Aboriginal communities were all used.&lt;/p&gt; &lt;p&gt;Discussion&lt;/p&gt; &lt;p&gt;The successful recruitment of 686 Indigenous subjects followed up 14 years later with vital status determined for 95% of subjects and examination of 86% shows an Indigenous birth cohort can be established in an environment with geographic, cultural and climatic challenges. The high rates of recruitment and follow up indicate there were effective strategies of follow-up in a supportive population.&lt;/p&gt;
    • Global plagues and the Global Fund: Challenges in the fight against HIV, TB and malaria

      Tan Darrell HS; Upshur Ross EG; Ford Nathan (BioMed Central, 2003-04-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Although a grossly disproportionate burden of disease from HIV/AIDS, TB and malaria remains in the Global South, these infectious diseases have finally risen to the top of the international agenda in recent years. Ideal strategies for combating these diseases must balance the advantages and disadvantages of 'vertical' disease control programs and 'horizontal' capacity-building approaches.&lt;/p&gt; &lt;p&gt;Discussion&lt;/p&gt; &lt;p&gt;The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) represents an important step forward in the struggle against these pathogens. While its goals are laudable, significant barriers persist. Most significant is the pitiful lack of funds committed by world governments, particularly those of the very G8 countries whose discussions gave rise to the Fund. A drastic scaling up of resources is the first clear requirement for the GFATM to live up to the international community's lofty intentions. A directly related issue is that of maintaining a strong commitment to the treatment of the three diseases along with traditional prevention approaches, with the ensuing debates over providing affordable access to medications in the face of the pharmaceutical industry's vigorous protection of patent rights.&lt;/p&gt; &lt;p&gt;Summary&lt;/p&gt; &lt;p&gt;At this early point in the Fund's history, it remains to be seen how these issues will be resolved at the programming level. Nevertheless, it is clear that significant structural changes are required in such domains as global spending priorities, debt relief, trade policy, and corporate responsibility. HIV/AIDS, tuberculosis and malaria are global problems borne of gross socioeconomic inequality, and their solutions require correspondingly geopolitical solutions.&lt;/p&gt;
    • Care for perinatal illness in rural Nepal: a descriptive study with cross-sectional and qualitative components

      Manandhar Madan; Manandhar Dharma S; Shrestha Bhim P; Tamang Suresh; Osrin David; Mesko Natasha; Standing Hilary; Costello Anthony (BioMed Central, 2003-08-01)
      &lt;p&gt;Abstract&lt;/p&gt; &lt;p&gt;Background&lt;/p&gt; &lt;p&gt;Maternal, perinatal and neonatal mortality rates remain high in rural areas of developing countries. Most deliveries take place at home and care-seeking behaviour is often delayed. We report on a combined quantitative and qualitative study of care seeking obstacles and practices relating to perinatal illness in rural Makwanpur district, Nepal, with particular emphasis on consultation strategies.&lt;/p&gt; &lt;p&gt;Methods&lt;/p&gt; &lt;p&gt;The analysis included a survey of 8798 women who reported a birth in the previous two years [of whom 3557 reported illness in their pregnancy], on 30 case studies of perinatal morbidity and mortality, and on 43 focus group discussions with mothers, other family members and health workers.&lt;/p&gt; &lt;p&gt;Results&lt;/p&gt; &lt;p&gt;Early pregnancy was often concealed, preparation for birth was minimal and trained attendance at birth was uncommon. Family members were favoured attendants, particularly mothers-in-law. The most common recalled maternal complications were prolonged labour, postpartum haemorrhage and retained placenta. Neonatal death, though less definable, was often associated with cessation of suckling and shortness of breath. Many home-based care practices for maternal and neonatal illness were described. Self-medication was common.&lt;/p&gt; &lt;p&gt;There were delays in recognising and acting on danger signs, and in seeking care beyond the household, in which the cultural requirement for maternal seclusion, and the perceived expense of care, played a part. Of the 760 women who sought care at a government facility, 70% took more than 12 hours from the decision to seek help to actual consultation. Consultation was primarily with traditional healers, who were key actors in the ascription of causation. Use of the government primary health care system was limited: the most common source of allopathic care was the district hospital.&lt;/p&gt; &lt;p&gt;Conclusions&lt;/p&gt; &lt;p&gt;Major obstacles to seeking care were: a limited capacity to recognise danger signs; the need to watch and wait; and an overwhelming preference to treat illness within the community. Safer motherhood and newborn care programmes in rural communities, must address both community and health facility care to have an impact on morbidity and mortality. The roles of community actors such as mothers-in-law, husbands, local healers and pharmacies, and increased access to properly trained birth attendants need to be addressed if delays in reaching health facilities are to be shortened.&lt;/p&gt;