Efficiency Of Health Service Delivery Research Articles

How does Public Financial Management (PFM) influence health system efficiency: A scoping review.

Effective Public Financial Management (PFM) approaches are imperative in the quest for efficiency in health service delivery. Reviews conducted in this area have assessed the impact of PFM approaches on health system efficiency but have left out the mechanisms through which PFM influences efficiency. This scoping review aims to synthesize evidence on the mechanisms by which PFM influences health system efficiency. We searched databases of PubMed and Google Scholar and websites of the World Health Organization (WHO), World Bank and Overseas Development Institute (ODI) for peer-reviewed and grey literature articles that provided data on the relationship between PFM and health system efficiency. Three reviewers screened the articles for eligibility with the inclusion criteria. Data on PFM and health system efficiency was charted and summarized. We then reported the mechanisms by which PFM influence efficiency. PFM processes and structures influence health system efficiency by influencing; the alignment of resources to health system needs, the cost of inputs, the motivation of health workers, and the input mix. The entire budget process influences health system efficiency. However, most of the findings are drawn from studies that focused on aspects of the budget process. Studies that look at PFM in totality will help explore other cross-cutting issues within sections of the budget cycle; they will also bring out the relationship between the different phases of the budget cycle.

Perceptions of pediatric residents and pediatricians about ethical dilemmas: The case of Turkey

BackgroundThis study determined the knowledge, attitudes, and behaviors of pediatricians and pediatric residents regarding issues of ethics, professional education, clinical ethical principles, and consent they encounter in health service delivery. MethodsParticipants in the study were 134 pediatricians and pediatric residents from three hospitals in Ankara, Turkey. Participants were asked questions regarding their sociodemographic characteristics, their knowledge and views of ethics and ethical education, whether they had ever encountered an ethical problem, their beliefs about obtaining consent from pediatric patients and their families, and case-based questions. All data were collected and evaluated. ResultsOf the participants in the study, 82 (61.2%) were residents, 41 (30.6%) were pediatricians, and 11 (8.2%) were faculty lecturers. The data revealed that 10% of the pediatricians and pediatric residents received ethical education, apart from medical ethics/deontology education at medical school, and 90.3% required further education on children and ethical problems. It was determined that 89% of residents and 78% of pediatricians needed help with the ethical problems they encountered during the diagnostic and treatment processes. Overall, 65.7% of the participants stated that the ethical problems they encountered affected the efficiency of health service delivery. It was observed that residents were more affected by ethical issues than pediatricians were. The present study revealed that pediatric residents and pediatricians need ethics education and there is a need to establish ethics counseling centers in hospitals. There is also a need for further studies in pediatrics and ethics.

A Survey of the Factors Affecting Theatre Turnaround Time in Kenyatta National Hospital Main Theatres

Operating theatres are heavily budgeted departments in health facilities. Theatre turnaround time (TAT) is used as one modality in determining the efficiency of health service delivery. Factors that correlate with TAT in the Kenyan setting are largely unknown. The main objective of this study was to determine the factors affecting turnaround time in Kenyatta National Hospital's main theatres.

The Experience of Strategic Partnership Between Başkent University and Semey Medical University on The Modernization of Medical Training

Since 1991 Kazakhstan has formed up a series of development projects regarding the modernization of the healthcare services. The formation of social health insurance and developments in medical education was followed by a Social Health Insurance Project to increase the accessibility, quality, and efficiency of health service delivery and reduce financial risks to the population caused by severe health problems. As a part of the Project, Semey Medical University and Başkent University became strategic partners to develop not only the education of the future medical doctors but also the management of the University Hospital. The project last for 21 months. Although pandemic restrictions caused some obstacles during the implementation of the project, all the tasks and activities were executed with a successful cooperation of the experts of both parties. The development of the curriculum, implementation of the Başkent University Medical Education Model, the modernization of the defined clinics as well as the development of the financial and strategic decision making of the governance were the main tasks of the project. The success of this partnership leads to new projects to enable the sustainability of the implemented models.Keywords: Kazakhstan, Semey Medical University, Başkent University, Başkent University Medical Education Model, Medical Education, World Bank, Project Implementation, Modernization, Healthcare Services.

Patient and health-care worker experiences of an HIV viral load intervention using SMS: A qualitative study.

BackgroundMobile Health or mHealth interventions, including Short Message Service (SMS), can help increase access to care, enhance the efficiency of health service delivery and improve diagnosis and treatment for HIV. Text messaging, or SMS, allows for the low cost transmission of information, and has been used to send appointment reminders, information about HIV counselling and treatment, messages to encourage adherence and information on nutrition and side-effects. HIV Viral Load (VL) monitoring is recommended by the WHO and has been progressively adopted in many settings. In Zimbabwe, implementation of VL is routine and has been rolled out with support of Médecins Sans Frontières (MSF) since 2012. An SMS intervention to assist with the management of VL results was introduced in two rural districts of Zimbabwe. After completion of the HIV VL testing at the National Microbiology Reference Laboratory in Harare, results were sent to health facilities via SMS. Consenting patients were also sent an SMS informing them that their viral load results were ready for collection at their nearest health facilities. No actual VL results were sent to patients.MethodsA qualitative study was conducted in seven health-care facilities using in-depth interviews (n = 32) and focus group discussions (n = 5) to explore patient and health-care worker experiences of the SMS intervention. Purposive sampling was used to select participants to ensure that male and female patients, as well as those with differing VL results and who lived differing distances from the clinics were included. Data were transcribed, translated from Shona into English, coded and thematically analysed using NVivo software.ResultsThe VL SMS intervention was considered acceptable to patients and health-care workers despite some challenges in implementation. The intervention was perceived by health-care workers as improving adherence and well-being of patients as well as improving the management of VL results at health facilities. However, there were some concerns from participants about the intervention, including challenges in understanding the purpose and language of the messages and patients coming to their health facility unnecessarily. Health-care workers were more concerned than patients about unintentional HIV disclosure relating to the content of the messages or phone-sharing.ConclusionThis was an innovative intervention in Zimbabwe, in which SMS was used to send VL results to health-care facilities, and notifications of the availability of VL results to patients. Interventions such as this have the potential to reduce unnecessary clinic visits and ensure patients with high VL results receive timely support, but they need to be properly explained, alongside routine counselling, for patients to fully benefit. The findings of this study also have potential policy implications, as if implemented well, such an SMS intervention has the potential to help patients adopt a more active role in the self-management of their HIV disease, become more aware of the importance of adherence and VL monitoring and seek follow-up at clinics when results are high.

Capacity of non-invasive hepatic fibrosis algorithms to replace transient elastography to exclude cirrhosis in people with hepatitis C virus infection: A multi-centre observational study.

IntroductionAchievement of the 2030 World Health Organisation (WHO) global hepatitis C virus (HCV) elimination targets will be underpinned by scale-up of testing and use of direct-acting antiviral treatments. In Australia, despite publically-funded testing and treatment, less than 15% of patients were treated in the first year of treatment access, highlighting the need for greater efficiency of health service delivery. To this end, non-invasive fibrosis algorithms were examined to reduce reliance on transient elastography (TE) which is currently utilised for the assessment of cirrhosis in most Australian clinical settings.Materials and methodsThis retrospective and prospective study, with derivation and validation cohorts, examined consecutive patients in a tertiary referral centre, a sexual health clinic, and a prison-based hepatitis program. The negative predictive value (NPV) of seven non-invasive algorithms were measured using published and newly derived cut-offs. The number of TEs avoided for each algorithm, or combination of algorithms, was determined.ResultsThe 850 patients included 780 (92%) with HCV mono-infection, and 70 (8%) co-infected with HIV or hepatitis B. The mono-infected cohort included 612 men (79%), with an overall prevalence of cirrhosis of 16% (125/780). An ‘APRI’ algorithm cut-off of 1.0 had a 94% NPV (95%CI: 91–96%). Newly derived cut-offs of ‘APRI’ (0.49), ‘FIB-4’ (0.93) and ‘GUCI’ (0.5) algorithms each had NPVs of 99% (95%CI: 97–100%), allowing avoidance of TE in 40% (315/780), 40% (310/780) and 40% (298/749) respectively. When used in combination, NPV was retained and TE avoidance reached 54% (405/749), regardless of gender or co-infection.ConclusionsNon-invasive algorithms can reliably exclude cirrhosis in many patients, allowing improved efficiency of HCV assessment services in Australia and worldwide.

Stakeholder perspectives of the Extended Scope Physiotherapy Practitioner (ESPP) role in Australia – a qualitative study

Background: A recent advancement in physiotherapy in Australia has been the development of Extended Scope Physiotherapy Practitioner (ESPP) roles. However, compared to the UK, ESPP roles in Australia have generally been introduced in a piecemeal fashion. To assist with defining ESPP roles and credentialing requirements for ESPP in Australia, we felt it was important to engage with context-specific key stakeholders. This study sought to understand the perceptions of a range of key stakeholders on the ESPP role in Australia, using qualitative interview techniques.Methodology: Semi-structured interviews were held with medical, nursing and allied health professional staff employed within an Australian health directorate who had reported experience with ESPPs.Findings: There was general consensus of the value of ESPP in improving the efficacy and efficiency of health service delivery, achieving positive patient outcomes and offering opportunities for interdisciplinary learning among colleagues. Participants agreed that physiotherapists were well placed to practice in an ESPP role in musculoskeletal clinical practice (orthopaedic clinics/ emergency departments), and that future opportunities may exist in the areas of women’s health, cardiopulmonary, and neurology physiotherapy. There was consistency that postgraduate courses should be accredited and tailored to the scope of ESP trainees. Core knowledge and skills required by ESPPs included ordering/interpretation of radiology, working with and educating staff from other disciplines, and triage, screening and early identification of musculoskeletal conditions.Finally, common barriers to the ESPP role in Australia were characterised as either ‘hard’ (legislative) or ‘soft’ (jurisdictional, professionally/culturally based).

Health policy dialogue: experiences from Africa.

Background The high volume of investments in health seen in Africa over the last decade, mainly through global health initiatives [1], has enabled significant improvements in some health indicators in many of the countries [2]. However, these gains have not always translated into sustained improvements in the health sector’s capacity or health system’s performance [3]. Countries in the World Health Organization African Region continue to face serious challenges among which are major inadequacies in the health workforce, low levels of health spending with significant out of pocket payments, weak procurement and supply systems, poor information and monitoring systems, [4] and weak community engagement [5]. The 2014–2016 Ebola virus disease outbreak in West Africa illustrated the importance of a functional health system in sustaining health service delivery and economic and social development amidst a crisis [6, 7]. Weaknesses in health sectors’ organisation and governance continue to undermine the efficiency of health service delivery [8]. The adoption of the 17 Sustainable Development Goals in September 2015 raises questions about the countries’ capacity to attain these new and broader goals when most of them failed to reach the targets of the Millennium Development Goals [4]. Realising the Sustainable Development Goals requires making good policy and strategic choices in the effort to achieve universal health coverage. Effective country stewardship, and governance and leadership of the health sector, along with ownership of the goals, will be needed to mobilise relevant stakeholders and to guide domestic and external investments towards the agreed goals. This will also require strengthening of partnerships, effective intersectoral engagement and collaboration, and community engagement. An important element in moving forward will be government leadership and coordination of effective policy dialogues and strategic planning to arrive at wellconsidered and evidence-based national health policies and sector strategic plans that are owned and supported by all stakeholders. In Africa, with its looming noncommunicable disease catastrophe and vibrant social, demographic and economic growth, sophisticated policy dialogue and evidence-based choices will increasingly be essential. The challenge of getting from research evidence to policy decisions will fare better with effective policy dialogue. The papers in this supplement review present recent experiences from some countries in the World Health Organization Africa Region from a programme to expand and support policy dialogue in the health sector. The experience has been illuminating with regard to the factors relating to the political players and processes, and the subjective elements that fuel policy debates. The themes of the papers were generated based on the critical questions on how policy dialogue would work in the various contexts found in a set of low income countries that receive substantial external aid inputs and therefore see significant influence in policy development and decision-making processes. It was important to determine what the enablers of effective policy dialogue were in those contexts and what incentives or motivators guided the stakeholders towards a viable policy dialogue. The papers highlight the fact that policy dialogue requires resources in terms of time, space, evidence, good facilitation, dialogue skills and advocacy. Informal and formal platforms need to be employed for consensus building, and potential influence and power imbalance need to be anticipated and mitigated. Often, as with any policy change or choice, there will be winners and losers—both metaphorically and concretely—in terms of access to health services and shifts in other interests. Understanding the impact of choices made should be a critical part of the dialogue processes. Timely and innovative dissemination of relevant information is needed to ensure that the dialogue is informed. * Correspondence: dovlod@who.int Health Systems and Services Cluster, World Health Organization Regional Office for Africa, B.P. 06 Brazzaville, Congo

Does integration of HIV and sexual and reproductive health services improve technical efficiency in Kenya and Swaziland? An application of a two-stage semi parametric approach incorporating quality measures

Theoretically, integration of vertically organized services is seen as an important approach to improving the efficiency of health service delivery. However, there is a dearth of evidence on the effect of integration on the technical efficiency of health service delivery. Furthermore, where technical efficiency has been assessed, there have been few attempts to incorporate quality measures within efficiency measurement models particularly in sub-Saharan African settings.This paper investigates the technical efficiency and the determinants of technical efficiency of integrated HIV and sexual and reproductive health (SRH) services using data collected from 40 health facilities in Kenya and Swaziland for 2008/2009 and 2010/2011. Incorporating a measure of quality, we estimate the technical efficiency of health facilities and explore the effect of integration and other environmental factors on technical efficiency using a two-stage semi-parametric double bootstrap approach.The empirical results reveal a high degree of inefficiency in the health facilities studied. The mean bias corrected technical efficiency scores taking quality into consideration varied between 22% and 65% depending on the data envelopment analysis (DEA) model specification. The number of additional HIV services in the maternal and child health unit, public ownership and facility type, have a positive and significant effect on technical efficiency. However, number of additional HIV and STI services provided in the same clinical room, proportion of clinical staff to overall staff, proportion of HIV services provided, and rural location had a negative and significant effect on technical efficiency.The low estimates of technical efficiency and mixed effects of the measures of integration on efficiency challenge the notion that integration of HIV and SRH services may substantially improve the technical efficiency of health facilities. The analysis of quality and efficiency as separate dimensions of performance suggest that efficiency may be achieved without sacrificing quality.

Lessons Learned From Using Focus Groups to Refine Digital Interventions.

There is growing interest in applying novel eHealth approaches for the prevention and management of various health conditions, with the ultimate goal of increasing positive patient outcomes and improving the effectiveness and efficiency of health services delivery. Coupled with the use of innovative approaches is the possibility for adverse outcomes, highlighting the need to strategically refine digital practices prior to implementation with patients. One appropriate method for modification purposes includes focus groups. Although it is a well-established method in qualitative research, there is a lack of guidance regarding the use of focus groups for digital intervention refinement. To address this gap, the purpose of our paper is to highlight several lessons our research team has learned in using focus groups to help refine digital interventions prior to use with patients.

Factors Influencing Utilization of Health Services in Kenya: The Case of Homa Bay County

In order to improve efficiency in health service delivery in Kenya, the Ministry of Health has developed structures through inter-sectoral collaboration at various levels. Despite efforts by the government and key stakeholders to improve health sector, utilization of health services still remains a major challenge. The purpose of the study was to investigate factors that influence utilization of health services in Homa Bay County, Kenya. The study employed survey design and focused on health beneficiaries, District Health Management Team and other key health stakeholders, and used both quantitative and qualitative data. Quantitative data was collected through household interviews of 384 respondents and qualitative data was generated through Key Informant Interviews of 16 respondents. The study reveals that health financing, service delivery, quality, accessibility and equity influence utilization of health services in Homa Bay County. It is for these reasons that the study recommends that the government should allocate adequate budget towards health services, avail adequate trained health workers, and improve infrastructure in health facilities as well as drugs and other supplies. There is also need for further research on cultural factors influencing utilization of health services.

Factors Influencing Utilization of Health Services in Kenya: The Case of Homa Bay County

In order to improve efficiency in health service delivery in Kenya, the Ministry of Health has developed structures through inter-sectoral collaboration at various levels. Despite efforts by the government and key stakeholders to improve health sector, utilization of health services still remains a major challenge. The purpose of the study was to investigate factors that influence utilization of health services in Homa Bay County, Kenya. The study employed survey design and focused on health beneficiaries, District Health Management Team and other key health stakeholders, and used both quantitative and qualitative data. Quantitative data was collected through household interviews of 384 respondents and qualitative data was generated through Key Informant Interviews of 16 respondents. The study reveals that health financing, service delivery, quality, accessibility and equity influence utilization of health services in Homa Bay County. It is for these reasons that the study recommends that the government should allocate adequate budget towards health services, avail adequate trained health workers, and improve infrastructure in health facilities as well as drugs and other supplies. There is also need for further research on cultural factors influencing utilization of health services.

Can physiotherapists contribute to care in the emergency department?

Throughout the history of healthcare practice, controversy has often surrounded instances of non-medical clinicians, such as allied health practitioners, undertaking roles traditionally performed by doctors. While this blurring of professional boundaries may occur in response to a need to enhance the efficiency of health service delivery, concerns invariably arise regarding the quality of care delivered by non-medical clinicians and the potential negative implications for patient safety.1 In recent years, physiotherapists have begun to practice in Australia’s emergency departments (EDs) as autonomous, primary contact clinicians responsible for many duties traditionally solely within the domain of the medical profession. Some controversy does exist around this development, and as such, gives rise to the following questions: Do physiotherapists deliver quality care in the ED? Has the introduction of physiotherapists to ED improved service delivery as intended? Decreasing waiting times and improving efficiency of patient management in EDs is a significant goal of modern healthcare delivery. Patients presenting with mechanical musculoskeletal pathologies can experience long waiting times in busy departments, as medical staff must prioritise higher triage category patients with more urgent medical issues. The use of suitably trained and experienced physiotherapists as primary contact clinicians has been implemented in EDs in the United Kingdom, Australia, and the United States, in an attempt to reduce waiting times for such patients, and to reduce clinical loads placed upon medical staff. Emergency department physiotherapists (EDPs) are responsible for the management of patients with semiurgent and non-urgent (Australian triage categories 4 and 5) musculoskeletal complaints. Their role includes undertaking patient interviews and examinations, ordering investigations such as X-rays, making a diagnosis, implementing suitable interventions, referring for ongoing management, and arranging patient discharge.2 EDPs may also contribute to the care of patients with acute respiratory conditions (e.g. secretion clearance interventions) or facilitate the discharge of patients from ED into the community to reduce preventable hospital admissions. Such clinicians practice autonomous to medical staff in the management of presentations within their scope of practice, such as ankle or knee sprains and mechanical back pain, in a similar capacity as a physiotherapist working in a private clinic. EDPs may also practice in collaboration with medical staff in the management of simple limb fractures, or as a secondary practitioner providing physiotherapy input to respiratory conditions or an opinion regarding musculoskeletal injuries. In Australia, as this role is outside the traditional duties of physiotherapists, this is termed “advanced practice”.3

Decentralization, Local Government Capacity and Efficiency of Health Service Delivery in Uganda

AbstractThe study investigates the impact of decentralization and local government capacity on efficiency of health service delivery in Uganda applying qualitative analysis, and two stage Data Envelopment Analysis (DEA) on quantitative data covering a sample of 44 districts over the period 2008/09 and 2009/10. The results show that health institutions in about 31 districts out of 44 were technically efficient, while those in about 13 districts were technically inefficient under variable returns to scale (VRS), implying that health resources were not efficiently used in these institutions. Health institutions in 56.8 percent and 45.5 percent of the districts were operating at optimal scale in 2008/09 and 2009/10, respectively. Those in the remaining districts were scale inefficient, with a majority of them operating under decreasing returns to scale (DRS). Effective and accountable decentralized governance in the health sector in Uganda is typically constrained by weak capacity, particularly under-staffing at the districts levels. Policy recommendations include strengthening professional staffing in some districts to improve their capacity to deliver efficient health services; transfers of officials from districts with excess capacity to those with inadequate resources; and districts whose operations are characterized by increasing returns to scale should be considered for future expansion to consolidate their efficiency.

An approach to classifying human resources constraints to attaining health-related Millennium Development Goals.

BackgroundFor any wide-ranging effort to scale up health-related priority interventions, human resources for health (HRH) are likely to be a key to success. This study explores constraints related to human resources in the health sector for achieving the Millennium Development Goals (MDGs) in low-income countries.Methods and frameworkThe analysis drew on information from a variety of publicly-available sources and principally on data presented in published papers in peer-reviewed journals. For classifying HRH constraints an analytical framework was used that considers constraints at five levels: individual characteristics, the health service delivery level, the health sector level, training capacities and the sociopolitical and economic context of a country.Results and discussionAt individual level, the decision to enter, remain and serve in the health sector workforce is influenced by a series of social, economic, cultural and gender-related determinants. For example, to cover the health needs of the poorest it is necessary to employ personnel with specific social, ethnic and cultural characteristics. At health-service level, the commitment of health staff is determined by a number of organizational and management factors. The workplace environment has a great impact not only on health worker performance, but also on the comprehensiveness and efficiency of health service delivery. At health-sector level, the use of monetary and nonmonetary incentives is of crucial importance for having the accurate skill mix at the appropriate place. Scaling up of priority interventions is likely to require significant investments in initial and continuous training. Given the lead time required to produce new health workers, such investments must occur in the early phases of scaling up. At the same time coherent national HRH policies are required for giving direction on HRH development and linking HRH into health-sector reform issues, the scaling-up of priority interventions, poverty reduction strategies, and training approaches. Multisectoral collaboration and the sociopolitical and economic context of a country determine health sector workforce development and potential emigration.ConclusionsKey determinants of success for achieving international development goals are closely related to human-resource development.

"Hacemos lo que podemos": los prestadores de servicios frente al problema de la utilización

This study presents the second part of the general results obtained by a qualitative study conducted within the National Health Survey II. The object of this study was to identify main patterns and micro-social determinants which affect the process of selection and utilization of health services in order to propose policies aimed at more equity, quality and efficiency in health service delivery. The study was conducted in urban areas among the middle and middle-low class sectors. A total of 192 individual open-ended interviews and eight focus groups were completed among health users in four cities. Also, 61 service providers both from public and private services were interviewed. Since a previous work reported findings related to health service users, this study focuses only on the results pertaining to health service providers. The first part briefly discusses the study design which allowed to explore the meaning that actors--health service providers--attach to their job and working conditions. The second part presents the main findings. The sense of economic and material precariousness with which health providers from public institutions do their work is among the most important results. Common conflicts between health service users and providers are also mentioned, mainly those which arise from the organizational problems of the health center and from the scarcity of the basic drug stock. The third part reports the main coincidences and divergences between health service users and providers. Some of the divergences may be the reason for the under-utilization of health services. The work concludes with a series of policy recommendations aimed at improving the quality and opportunity of health services provided by public institutions for the needs of the population.

The politics of trauma system development.

Federal and state policymakers have turned to health planning programs as a means to rationalize the delivery of health care services in the United States for over 3 decades. Early federal initiatives such as the Comprehensive Health Planning Act of 1966 and the Health Planning and Resource Development Act of 1974 were widely criticized for their inability to control costs effectively or to increase the efficiency of health services delivery. The design and implementation of the federal government's latest entry into health planning, the Trauma Care System Planning and Development Act of 1990 (Pub. L. 101-590), suggests that federal and state officials are poised to repeat the mistakes that plagued previous planning programs. The implementation of Pub. L. 101-590 illustrates the dilemmas that federal and state officials must confront in achieving effective representation and ensuring active participation in the planning process. Successful regional and statewide planning ventures must devise strategies to overcome the inherent collective action problems associated with cooperative solutions to underserved populations. Contemporary approaches to health planning, however, are based on a number of questionable assumptions. The creation of new institutional structures merely shifts the venue for existing conflicts among health providers, third-party insurers, and other participants in the health policymaking process to a new arena. In addition to examining possible alternatives for improving current trauma system planning initiatives, this paper presents a new paradigm for designing and implementing state and federal planning programs.

Surveillance of diagnostic and treatment measures in Bavaria, 1974–1976: Results 2 and 5 years after the start of chemotherapy

A central surveillance register for all bacillary pulmonary tuberculosis cases reported in Bavaria (population in excess of 10 million) was established from 1974 to 1976. The aim of the study was to discover the quality and efficiency of health services delivery to the population in the field of tuberculosis under routine conditions, and to find out the relapse rate after cessation of chemotherapy in expatients who were found to be negative 2 years after starting chemotherapy. A total of 7850 German patients with bacillary pulmonary tuberculosis were diagnosed in Bavaria from 1974 to 1976 corresponding to an average annual rate of 25.7 per 100 000 population: 71 % of them were smear-positive and 29 % were positive by culture only. Reactivations formed 25 % of all bacteriologically confirmed cases. Most (71 %) smear-positive new cases were discovered because of symptoms. Of the 5157 cases of bacteriologically confirmed pulmonary tuberculosis reported during 1975 and 1976,4 % died from tuberculosis, 1 % from sequelae of tuberculosis and 9 % from causes other than tuberculosis. A further 3 % of patients had drug side-effects, 3 % were uncooperative, 2 % emigrated or had no permanent address and 1 % had no chemotherapy or no information on treatment. The overall results of treatment were very satisfactory: sputum conversion among 3991 patients in the group with complete treatment was achieved in 97.4 % at 2 years, and in those with incomplete treatment in 96.2 %. The duration of chemotherapy was long, i.e. 19 months or more in two thirds of the patients. The average reactivation rate during the 3rd, 4th and 5th follow-up years was 0.8 % annually; it was higher among males than females and the rate increased with age. Of the 157 patients found to be bacteriologically positive at 2 years after the start of chemotherapy 46 died during the 3-year observation period and 109 were alive at 5 years, 23 of whom were harbouring tubercle bacilli.