Existing Health Care System Research Articles

Spinal Cord Injury in Postearthquake Haiti: Lessons Learned and Future Needs

D C ust before 5 PM on January 12, 2010, a 7.0 earthquake struck Haiti, a Caribbean nation that hares the island of Hispaniola with the Dominican Republic. The epicenter was approxiately 10 miles southwest of Port-au-Prince, the capital of Haiti. Port-au-Prince is the ountry’s largest city and is an overcrowded, sprawling urban center with a population efore the earthquake of approximately 3 million people, including the surrounding areas. he earthquake was devastating and more than twice as lethal as any previous magnitude .0 event [1]. Precise totals will never be known, but current United Nations estimates are 50,000-300,000 deaths, which is more than twice that of the atomic bomb dropped on iroshima at the end of World War II [2]. In addition, there were 300,000 injuries and 45,000 buildings were destroyed (Figure 1), which rendered 1.5 million Haitians homeess, most of whom are now living in tent cities [1-3]. Before the earthquake, Haiti was the poorest nation in the Western Hemisphere and was anked 149 on the 2009 Human Development Index [4]. The existing health care system as tenuous, and the majority of Haitians did not have access to regular health services. lthough the response from the international community was swift and massive, first esponders were still placed in the unenviable position of having to ration medical care ecause the sheer magnitude of the tragedy outstripped available resources. Some facilities ecided not to treat catastrophic injuries, such as spinal cord injuries (SCI), because of the esource intensive needs of these patients, perceived low survival rates, and “minimal hance of ultimate rehabilitation . . .” [5]. Nevertheless, despite the challenging circumtances, initial efforts led to the stabilization and survival of many individuals with injuries hat would have likely been life-threatening in pre-earthquake Haiti. Before the earthquake, individuals living with severe SCIs were largely nonexistent in aiti. Although the exact number and survival rate before the earthquake is unknown, the eeling among rehabilitation professionals with long-standing involvement in Haiti is that ndividual cases were sporadic and that persons with severe injuries, if they survived the nitial injury and acute period, typically died within the first 1-2 years. This would be onsistent with other developing nations. Under these circumstances, there was little need or expertise in the delivery of care to individuals with SCIs. Likewise, there were no true npatient rehabilitation beds for individuals with SCI. The events of January 12 led to an unprecedented number of SCIs. A preliminary report y Handicap International estimated that there were more than 100 survivors with SCIs [6]. he number is now thought to be closer to 150 despite the fact that most persons with ervical injuries did not survive. The situation was compounded by damage to medical acilities, for example, the General Hospital in Port-au-Prince. An undetermined number of ersons with SCIs were transferred to facilities outside Haiti, including the United States. iven that acute care facilities were stretched beyond their capacity, an urgent need arose for atients to be discharged to alternative settings once stabilized. Under these difficult and ire circumstances, 3 organizations established SCI units to address this pressing need: Haiti ospital Appeal (HHA) in Cap-Haitien (northern Haiti), Project Medishare/Univeristy of iami in Port-au-Prince (central Haiti), and St. Boniface Hospital in Fond-des-Blancs southern Haiti). Currently these facilities are caring for approximately 60 individuals with CI. Two authors (A.S.B., M.D.L.) were recently part of an interdisciplinary team from the oronto Rehabilitation Institute (TRI) that, in partnership with Team Canada Healing S c

The Centralization and Decentralization of Telemedicine Networks in Korea and Japan

This study scrutinizes telemedicine networks with regard to regionalization and the propensities and determinants of core telemedicine users (doctors and patients) by employing two case areas, Choongbook in Korea and Kagawa in Japan. According to the results, telemedicine networks in Choongbook are dominated by an inter-regional level (in particular, a national level), and most of the telemedicine networks are observed between clinical sites in Choongbook and tertiary care centers in Kyunggi. In contrast, telemedicine networks in Kagawa are dispersed within the diagnostic boundary of Kagawa at a regional level. Interviews with crucial decision-makers revealed the reasons why many patients enjoy health care via telemedicine at an inter-regional level, which include psychological considerations regarding quality and level of health care services, personal stakes in telemedicine service sites, acceptability and credibility of good tertiary care centers, and easy access to and use of medical institutions. In Kagawa, both the existing health care system and the telemedicine system support the maintenance of stable regional health care within Kagawa. Importantly, human relationships based on the regional health care system contribute to creating telemedicine networks within the original purpose of the telemedicine system regarding regionalization. Also, telemedicine’s technological value, convenience, and utility are associated with the regionalization of telemedicine networks within one diagnostic area.

Young Adults Are Worse Off Than Adolescents

Young Adults Are Worse Off Than Adolescents

Redesign of the Health Care Delivery System

THE GOVERNING DESIGN PRINCIPLE OF THE US HEALTH care system has been described as an “edifice complex” and a “field of dreams” complex—if the health system builds it, the patients will come. This clinician-centric approach to the design of delivery of health care is obsolete, contributing to health care of inferior quality and excessive cost. To meet the patient-centered needs of a modern health care system, the United States should consider adopting the Bauhaus design principle of “form follows function.” Form follows function was the guiding principle of the Bauhaus school of crafts and architecture, founded in Germany in 1919 by Walter Gropius. The structure of a chair or house was to follow logically from the intended function of that form. The Bauhaus movement emphasized rational and simplified design, reconciling craftsmanship and technology under a spirit of populism and modernism. These principles are applicable to the design of a modernist health system. Traditionally, approaches to health care delivery design view the extravagantly rococo structure of the existing health care system and propose additions or minor alterations to this dysfunctional structure. What if there was a different starting point—the intended function of the health system— and planners worked backward to determine the form most suitable to that function?

Majority of Physicians Back Public Option in Health Reform

Back to table of contents Previous article Next article Government NewsFull AccessMajority of Physicians Back Public Option in Health ReformRich DalyRich DalySearch for more papers by this authorPublished Online:16 Oct 2009https://doi.org/10.1176/pn.44.20.0006A national survey of psychiatrists and other physicians found that most of them support inclusion of a government-funded option in any legislative effort to overhaul the existing health care system dominated by the private health insurance industry.The summer-long survey, to which 2,130 physicians responded, asked them which of three options for expanding health insurance coverage they supported the most: combining public and private options, expanding access to private options only, or covering everyone through a single public plan like Medicare does. A substantial majority of physicians (62.9 percent) said they supported a combination of public and private insurance plans. The survey was conducted by Salomeh Keyhani, M.D., M.P.H., an assistant professor of medicine at Mount Sinai School of Medicine, and Alex Federman, M.D., M.P.H., an assistant professor of general internal medicine also at Mount Sinai. The findings were published in the September 14 New England Journal of Medicine.While 27.3 percent of physicians said their first option was a system based on private insurance options, only 9.6 percent of respondents supported a reform plan that relied solely on a government-funded insurance, such as a nationwide expansion of Medicare. However, 58.3 percent of the physician respondents supported an expansion of Medicare to Americans as young as age 55.While the survey report did not disclose the number of psychiatrists who participated, the authors pointed out that responses were consistent across physician specialties, practice settings, and regions of the country.“Regardless of their preferred solution, the majority of APA members would want to see parity principles recognized, appropriate physician reimbursement, and voluntary participation in any reform plans that emerge from Congress,” said Irvin “Sam” Muszynski, J.D., director of APA's Office of Healthcare Systems and Financing.In September APA's Board of Trustees voted unanimously to support America's Affordable Health Choices Act (HR 3200) as the basis for health care reform (see Original article: APA Board Takes Stance on Health Reform Proposals). That bill—approved by three House of Representatives committees and previously endorsed by the AMA and other groups—includes the most aggressive government-funded insurance program, or public option, of the major health reform bills advancing through Congress.The APA Board's support was based in part on the bill's requirement that its proposed Health Insurance Exchange feature include the option of a public health insurance program. The bill clarifies that physician participation in a public plan would be voluntary and that no penalties may be levied against physicians who choose not to participate.The survey and the APA Board's actions came as the Obama administration and its allies explicitly called for physicians to help educate their patients about the need for a health system overhaul and how it could benefit them.“It's especially important that we have doctors speaking up in their communities for the change that our health system needs,” said Vivek Murthy, president of Doctors for America, a liberal advocacy group, during a September 17 White House conference call for physicians.Previous surveys on physicians' views of health reform proposals asked about somewhat different national health insurance questions and received varying answers. One survey of 1,650 physicians published in the November 2003 Annals of Internal Medicine found, for example, that 49 percent of physicians supported legislation to establish national health insurance, but only 26 percent supported a federally funded national health insurance plan. A majority of psychiatrists in that survey supported national health insurance, but less than 50 percent of them backed the federal government as the sole payer of national health insurance.“Doctors on Coverage—Physicians' Views of a New Public Insurance Option and Medicare Expansion” is posted at<http://healthcarereform.nejm.org/?p=1790>.▪ ISSUES NewArchived

Leveraging the role of public health nursing in managing HIV/AIDS in Thailand: A journey of international collaboration

Thailand is one of the first countries to have achieved significant advances in control over the HIV/AIDS epidemic occurring within its borders. Despite this impressive accomplishment, the disease continues to be a Leading cause of death in Thailand and is migrating into Thai populations heretofore relatively free of it, such as married women. In 2003, a unique Thai, American, academic, and government collaboration formed to address the on-going challenges of HIV/AIDS in Thailand and its emerging characteristics. The objective of this collaboration was to increase the capacity of Thailand's public health infrastructure to address the challenges of HIV/AIDS by utilizing a Larger and more empowered role for nurses within the country's existing health care system. This collaboration consisted of the Deans' Consortium of Nursing Educational Institutions, the Thai Ministry of Public Health, the Faculty of Nursing at Mahidol University, and United States university nursing educators. This paper describes the process that brought this collaboration into being. It also describes the outcomes achieved by this collaboration; a collaboration that realized a national strategy to Leverage and expand the role of public health nurses and the initiation of a nurse practitioners' role in the prevention and treatment of HIV/AIDS. This collaboration and strategy increased the capacity of the health care system in Thailand to more effectively meet the challenges posed by all infectious diseases in Thailand and, in particular, HIV/AIDS.

A Practical Framework for Patient Care Teams to Prospectively Identify and Mitigate Clinical Hazards

One of the greatest challenges facing both practitioners and risk managers is the identification of previously unknown clinical hazards and defects. With the rapid proliferation of new health care services, unknown hazards may propagate as new therapies are integrated into the existing health care system. The main goal of risk analysis is to make these hazards visible by proactively searching and probing the system. Yet, a comprehensive approach by which to safely integrate new therapies into the existing clinical environment has yet to be clearly articulated. Patient care teams can use the proposed framework when introducing new therapies. The framework includes a background investigation and literature search; an in situ simulation (in the actual clinical setting used for patients); a Failure Mode and Effects Analysis to determine the severity, probability, and risk of the potential hazards; and a multidisciplinary protocol and safety checklist to standardize practice and ensure provider accountability. Application of this framework to three operative scenarios--intraoperative radiation therapy (IORT), hyperthermic intraperitoneal chemotherapy (HIPEC), and an interventional pulmonology program--demonstrates its flexibility. Its use prospectively identified and mitigated 20 IORT, 5 HIPEC, and 18 interventional pulmonology hazards/defects. Subsequent patient cases were largely uneventful. All cases and patient safety reporting systems are monitored to identify any new defects in an effort to continuously improve patient care. The use of a comprehensive framework to identify and mitigate hazards in an on-site simulated environment promotes safer care for target patient populations; results in familiarity with procedures, amelioration of staff concerns, and standardization of practice; and facilitates teamwork and communication.

The Advantages and Limitations of International Classification of Diseases, Injuries and Causes of Death from Aspect of Existing Health Care System of B and H

CONFLICT OF INTEREST: NONE DECLAREDIntroductionThe International classification of diseases (ICD) is the most important classification in medicine. It is used by all medical professionals.ConceptThe basic concept of ICD is founded on the standardization of the nomenclature for the names of diseases and their basic systematization in the hierarchically structured category.Advantages and disadvantagesThe health care provider institutions such as hospitals are subjects that should facilitate implementation of medical applications that follows the patient medical condition and facts connected with him. The definitive diagnosis that can be coded using ICD can be achieved after several visits of patient and rarely during the first visit.ConclusionThe ICD classification is one of the oldest and most important classifications in medicine. In the scope of ICD are all fields of medicine. It is used in statistical purpose and as a coding system in medical databases.

What Are Bioethicists Doing about Health Care Reform?

Health care reform is once again in the air. Everyone is excited--probably too excited--about the possibility that reform could be enacted next year. As the debate evolves and intensifies, it behooves those of us interested in bioethics to ask ourselves What are we doing to promote reform? Talking about reform and avowing our sincere support for are easy. The bigger challenge is to gauge whether the bioethical decisions we make, the advice we offer, and the positions we espouse are furthering or hindering sustainable reform. It might be good to begin by considering two important lessons that the reform effort in Massachusetts has made clear. Lesson 1: A Massachusetts-style reform cannot possibly achieve coverage. Only comprehensive reform of the financing system can achieve true coverage. Jonathan Gruber, one of the chief architects of the Massachusetts reform, describes it as a fill in the cracks plan or, as he put it in another characterization, universalism. The Massachusetts plan attempts to come as close to with as few changes to the existing health care system as possible. It largely leaves the existing financing and delivery systems in place. The major changes are a mandate to purchase insurance, state subsidization to do so, and the insurance exchange--called a Connector in Massachusetts--to standardize insurance offerings and reduce administrative costs (underwriting, sales, and marketing). Unfortunately, even with a mandate and the most optimal confluence of factors, this incremental mandate reform could never achieve true health coverage. At best, it was going to get 97 percent of the population insured. This could be described as universal coverage only by economists who also believe 4 percent unemployment is full employment. While there are good economic reasons to have a small level of unemployment--it prevents labor shortages that slow economic production and spur inflation and is necessary for people who are transitioning between jobs--there are no comparable arguments for less than 100 percent health care coverage. Having 3 percent of the population uninsured is certainly better than having 15 percent uninsured, but it is still not universal. Less than 100 percent is a policy failure because it is neither a political necessity nor an economic imperative. Why will the Massachusetts plan never achieve coverage? Massachusetts mandates the purchase of an insurance package and subsidizes it for families earning up to 300 percent of the federal poverty level--roughly $61,000 for a family of four. With such a policy, two groups will still lack insurance. The first are the young and healthy who will evade the mandate, calculating that the penalty for not having insurance and needing care is less costly than buying what they think is unnecessary coverage. More important are the families earning $60,000 to $80,000 (300 percent to 400 percent of poverty) whose employers do not provide health insurance. Clearly, these families are not poor--they earn above the median income. But, realistically, a family health insurance policy that costs $12,000--for them, roughly 15 to 20 percent of pretax income--is unaffordable. Accordingly, in Massachusetts, they are exempted from the mandate. This last category constitutes about 3 percent of the population. This means that even in the best case scenario, only 97 percent of the Massachusetts population will be insured. Obviously, it is theoretically possible for the state to subsidize this group, but subsidizing families up to 400 percent of poverty--roughly 62 percent of the population--would raise the cost for the program enough to make it fiscally impossible. Those who are dedicated to true should not be satisfied with the Massachusetts approach--mandate or no. True coverage--covering 100 percent of the population--requires significantly changing the health care financing system. …

Cultural Leverage

The authors reviewed interventions using cultural leverage to narrow racial disparities in health care. Thirty-eight interventions of three types were identified: interventions that modified the health behaviors of individual patients of color, that increased the access of communities of color to the existing health care system, and that modified the health care system to better serve patients of color and their communities. Individual-level interventions typically tapped community members' expertise to shape programs. Access interventions largely involved screening programs, incorporating patient navigators and lay educators. Health care interventions focused on the roles of nurses, counselors, and community health workers to deliver culturally tailored health information. These interventions increased patients' knowledge for self-care, decreased barriers to access, and improved providers' cultural competence. The delivery of processes of care or intermediate health outcomes was significantly improved in 23 interventions. Interventions using cultural leverage show tremendous promise in reducing health disparities, but more research is needed to understand their health effects in combination with other interventions.

Determinants of child malnutrition during the 1999 economic crisis in selected poor areas of Indonesia.

There is empirical evidence at the national level that suggests the 1999 Indonesian economic crisis impact was very heterogeneous both between urban and rural areas and across regions. A cross sectional study of the nutritional status of children and its determinants was performed in urban poor areas of Jakarta, and rural areas of Banggai in Central Sulawesi, and Alor-Rote in East Nusa Tenggara. Two-stage cluster sampling was used to obtain 1078 households with under-five children in the urban poor area of Jakarta, and 262 and 631 households with under-five children each for the rural areas of Banggai and Alor-Rote, respectively. Data collection for both studies was performed from January 1999 to June 2001. The study shows that wasting affected more children in the urban poor areas of Jakarta than in the other study areas. On the other hand, stunting and anemia were significantly more severe among children 6-59 months of age in the rural area of Alor-Rote compared to the other study areas. The high prevalence of infectious diseases was significantly related to the higher prevalence of wasting in the study areas of Jakarta and Banggai, and also significantly related to the higher prevalence of stunting and anemia in the study area of Alor-Rote. To avert this kind of health impact of a economic downturn, there is a need to improve the nutritional and health status of under-five children and their mothers through the existing health care system, provide basic health services and improve the capacity of health staff across Indonesia as part of the decentralization process.

Nurse recruitment and retention: Imperatives of imagining the future and taking a proactive stance

The need to imagine, examine, study, take a proactive stance in regard to and make a steadfast commitment to the future of nursing has never been more imperative. As Bezold et al. (1999: 4) persuasively argue, the nursing profession (and others) have:never had a greater need to understand the future, to envision a preferred future, and to develop strategies to create the preferred future than it does today. Vision and commitment are needed more than ever.The reasons for this are twofold. First, the nursing profession world-wide is facing a crisis in recruitment and retention. This crisis, widely recognised as involving 'the worst nursing shortage in the last 50 years' (Hodges et al. 2002), is having a significant and negative impact on health care and the capacities of the health care systems around the world (including the Australian health care system) to respond appropriately, safely, and effectively to the health needs of the individuals, groups and communities they serve. There is a critical need for stakeholders to collectively and creatively 'think and work' their way out of this crisis.A second key reason is that the health, welfare and well-being of both current and future generations depends on the access, equity, quality and viability of professional nursing services. The accessibility and sustainability of quality nursing services, in turn, depend on nursing futures work and the capacity of this work to 'confront the will to act' in regard to the realisation ol a preferred healthier future for all (Bezold et al. 1999: 4). In sum, the future of nursing is imperative because:Nursing's future is inextricably, and rightly so, bound to society's future and the future of health care. (Bezold et al. 1999: 8)AUSTRALIAN HEALTH CARE CRISISFew would disagree that Australian health care is in a crisis. Despite policies that advocate access and equity to Australia's health care services, thousands of Australians do not have timely access to appropriate and effective health care. Furthermore, as is the case in the United States of America, in Australia:* health care costs are increasing, in spite of efforts to contain costs;* quality of care is decreasing in spite of increasing regulations to enhance quality care; and* the existing health care system is reactive rather than proactive (Jardin 2001: 615).A key contributor to the present crisis in Australian health care is the local and global shortage of registered nurses (Duffield & O'Brien-Pallas 2003; Preston 2006). This shortage is not only affecting patient care delivery, but also the education of nurses on account of their being a commensurate decline in the nurse educator workforce - a problem that has not yet been formally recognised or strategically addressed in Australia.In Australia, nurses constitute the largest group of health care professionals, with 30% being employed in the health care sector (National Review of Nursing Education 2001 : 10). Nurses provide care across the continuum of care and work within a wide range of models of service 'which are constantly evolving due to advances in science and technology, consumer expectations, an aging population and the drive to find efficiencies in an industry where expenditure continues to increase' (National Review of Nursing Education 2001: 10).The current nursing shortage is serious. Not only does the shortage of nurses threaten the quality and safety of patient care (Duffield & O'Brien-Pallas 2003), but also 'the economic viability of the hospitals and other health care agencies where [nurses] are employed' (Hodges et al. 2001: 15). As the Key Performance Indicators (KPIs) of most Australian hospitals currently demonstrate, when there are insufficient numbers of registered nurses available, beds have to be closed, wait times in emergency departments increase, ambulance by-pass rates increase, delays are experienced in elective surgery as well as emergency surgery, intensive care admissions, and general medical-surgical admissions - all of which have a significant (negative) effect on a health care facility's funding entitlements and overall economic performance. …

The Health Care Financing Maze for Working-Age People with Disabilities

People with disabilities often require substantial medical services and supports to lead fulfilling lives. Health care expenditures for working-age people with disabilities are almost four times the expenditures of their counterparts without disabilities, about $8,300 per year in 2003, compared with $2,100 per year on average (Agency for Healthcare Research and Quality 2003). These expenditures are covered by variety of sources: private health insurance, Medicare, Medicaid, and wide variety of other public health care programs. In 2002, federal expenditures for the health care of people with disabilities totaled an estimated $102 billion, mostly under the Medicare and Medicaid programs ($93 billion); states paid an additional $45 billion (Goodman and Stapleton, 2005). Despite high level of public spending on medical care for working-age people with disabilities, the existing health care system is not adequately meeting the needs of this diverse population. Access to services is often determined by age, income, disability type, current work status and previous work experience, and many people face major gaps in needed services. The health care financing system is complicated by the fact that major financiers of health care for people with disabilities - primarily the states, the federal government, employers, and the individuals and their families - have, over the years, sought to reduce their own costs by shifting liabilities to each other. As the cost of health care has increased, so has the intensity of cost-shifting efforts. As result, the financing of health care for people with disabilities, especially long-term care, and other forms of chronic care services, resembles a multidimensional, temporally endless game of hot potato, in which beneficiaries and the services they need are regularly tossed from one set of hands to another - and often fall on the floor in the process (Vladeck, 2001). Making matters worse is the fact that access to financing is linked to work status. The public/private health insurance system can make it difficult for people with disabilities to move into and out of the labor market because most private coverage is obtained through employers and most public coverage is linked to determination of inability to work. Recent initiatives, most notably the Medicaid buy-in programs, authorized by the Balanced Budget Act of 1997 and the Ticket to Work and Work Incentives Improvement Act of 1999, have attempted to break the link between public health insurance eligibility and employment, but have had only moderate success and serve to further complicate the system (Goodman and Livermore, 2004). Much of the research on health care financing for people with disabilities has focused on the Medicaid and Medicare programs. The findings of this research often highlight the inadequacies of those programs in providing appropriate services to address the special needs of people with disabilities. A focus on these large programs, however, obscures the role of other public and private insurers, as well as the role of programs that provide many additional services to this population – all of which add complexity to the system. The purpose of this paper is to describe the financing system as whole, including the large public programs, other public and private insurers, and the many other programs that provide additional services. The description of the system highlights structural problems that need to be addressed in order to substantially improve the delivery of health and related services to people with disabilities. In the next section, we describe each source of health care financing for working-age people with disabilities and highlight its implications for service delivery and quality of life. In the concluding section, we describe the key structural shortcomings of the current financing system, assess the extent to which current reform efforts are addressing these shortcomings, and discuss the implications for broader efforts to reform health care financing system.

Calif. Physicians See Perils in Insurance Reform Plan

Calif. Physicians See Perils in Insurance Reform Plan

Appropriate Management of Severe Malnutrition Greatly Contributes to the Reduction of Child Mortality Rate

Appropriate Management of Severe Malnutrition Greatly Contributes to the Reduction of Child Mortality Rate

Good governance and sustainability: a case study from Pakistan

On the basis of a case study in Pakistan, the paper argues that good governance, characterized by transparency, accountability and meaningful community participation, plays a critical role in the sustainability of donor-funded health systems projects in the public health sector. The Family Health Project (FHP) (1992-1999), funded by the World Bank, has been used as a case study. Critical analysis of secondary data mainly obtained from the Department of Health (DoH) in the province of Sindh in Pakistan is the major tool used for the study. Data from other sources including the World Bank have also been used. The analysis reveals that the existing health care system could not fully absorb and sustain major "sociopolitical" thrusts of the project, meaningful community participation and "democratic" decision-making processes being the most important ones. The hierarchical structure and management process made it difficult to produce a sense of ownership of the project among all managers and the rank and file staff. The Provincial Health Development Center (PHDC) and District Health Development Centers (DHDCs) established by the FHP did not receive adequate financial and political support from DoH and the Ministry of Health to have much control of the project at the local level. Consequently, these Centers largely failed to institutionalize a continuing training program for district level health officials/professionals. Due to lack of political support, the District Health Management Teams (DHMTs) could not be institutionalized. Community participation in the DHMTs was symbolic rather than forceful. Improved coordination among all stakeholders, more stable and competent leadership, more meaningful community participation, greater devolution of project management to the district level, and better management of resources would have resulted in more effective and efficient implementation of the project. Based on these findings, the paper introduces a Sustainable Management Approach (SMA) as a tool that can be used to ensure the sustainability of health systems projects, particularly those funded by international organizations in developing countries. Good governance and a conducive organizational culture are important prerequisites for incorporating any new project within an existing system. This includes prior consensus building among all stakeholders, a meaningful and inclusive participatory planning, implementation and evaluation process involving communities, political commitment, and the identification and use of appropriate leadership for project management.

Chronic kidney disease and its prevention in India

Chronic kidney disease (CKD) is an important, chronic, noncommunicable disease epidemic that affects the world, including India. Because of the absence of a renal registry in India, the true magnitude of CKD/end-stage renal disease (ESRD) is unknown. Two community-based studies, although methodologically different, have shown a prevalence of chronic renal failure of 0.16% and 0.79%. The cost of maintenance hemodialysis for a single session varies between 10 US dollars to 40 between government-run and private hospitals. The average cost of erythropoetin is approximately 150 US dollars to 200 per month. The cost of chronic ambulatory peritoneal dialysis with "Y" set at 3 exchanges per week, which most patients in India do, is US 400 US dollars per month. The cost of a renal transplant (RT) procedure is approximately US 700 US dollars to 800 in the government sector and 6000 US dollars in the private sector. The cost of immunosuppression with basic triple immunosuppression drugs (cyclosporine, steroid, and azathioprin) is US 250 US dollars per month. There are hardly any state-funded medical treatment and medical insurance facilities for CKD and ESRD patients in India. India has nearly 700 nephrologists and approximately 400 dialysis units with 1000 dialysis stations, with the majority being in the private sector. A maximum of 2% of patients can be subjected to maintenance hemodialysis. Until now, approximately 3000 patients have been initiated on chronic ambulatory peritoneal dialysis. India has approximately 100 RT centers, mostly in private setup, and not more than 3000 to 4000 RTs are performed annually. Thus, only 3% to 5% of all patients with ESRD in India get some form of renal replacement therapy. Thus, planning for prevention of CKD on a long-term basis is the only practical solution for India. It appears that even in India, diabetes and hypertension are responsible for 40% to 50% of all cases of chronic renal failure. Screening for these 2 diseases and CKD is simple and easy to perform. The best approach will be to start screening for CKD in a high-risk group, like first-degree relatives of patients with diabetes, hypertension, and CKD, and simultaneously making a platform to run the program through the existing health care system of the country. The key issue of funding the program needs to be explored. Initial funding may come from international agencies like the World Health Organization, World Bank, and International Society of Nephrology, along with support from the country itself. Ultimately, funding has to be sustained from our own existing health care system.

Electronic and telemedicine techniques to manage heart failure

Electronic monitoring and telemedicine techniques are effective tools to manage patients with moderate and high risk heart failure as part of a multidisciplinary disease management system. They have been shown to reduce hospitalization and emergency room visits, improve quality of life, and possibly impact mortality. In addition, several have been shown to be cost-effective. They encourage patient education and self-management and facilitate guideline-mandated care. These technologies can improve efficiency by allowing a single clinician to closely manage many patients in a high-quality manner. Simultaneously, these systems can burden the existing health care system by adding large volumes of new data that need to be reviewed and acted upon. Payers must develop realistic reimbursement schemes to offset the costs of supervising these systems. Newer devices that collect many physiologic variables, including some that invasively record ambulatory hemodynamics, add significant complexity, but it is unclear whether this additional data will improve management and outcomes to justify the incremental risks and costs.

Medicinal Plants in Urban Districts of Tanzania: Plants, Gender Roles and Sustainable Use

SUMMARY An ethnobotanical survey was carried out to collect information on medicinal plants and gender roles in sustainable use by urban communities of Morogoro and Iringa districts, Tanzania. A total of 99 and 75 medicinal plant species distributed in various genera and vascular plant families, curing about 72 and 57 human diseases, were reported in the two districts respectively. Results showed significant gender roles difference in sustainable use of medicinal plants. Most men herbalists used roots while women preferred barks. Uprooting during plant harvesting was agreed to exist by most men herbalists in Morogoro. The majority of men and women herbalists supported the idea of conserving medicinal plants in order to ensure their sustainability in future. Since medicinal plants play an important role in the livelihoods of urban dwellers, their loss due to unsustainable exploitation will obstruct the existing health care system unless conservation measures are taken. There is a need to sensitize and trai...

An Ethnobotanical Study of Medicinal Plants used by the Lisu People in Nujiang, Northwest Yunnan, China

An ethnobotanical survey was carried out to collect information on the use of medicinal plants by the Lisu people who live in the mountainous areas of the Nujiang Canyon (Salween River Valley) in Nujiang Prefecture, northwestern Yunnan Province, China. A total of 52 medicinal plants, belonging to 32 families, were reported as being used locally for the treatment of human ailments. The scientific and Lisu names, parts used, and preparation of the plants are presented. Most of these species are wild (80%), while others are domesticated (8%) or semi-cultivated (12%). Among the 52 species, 11 species (21.2%) were reported as rare and 16 were widely commercialized in the region. Over-exploitation and deforestation are the main causes for the depletion of medicinal plants in this area. The Lisu people still mostly depend on medicinal plants for their health care. The loss and endangered status of these plants will, to a certain extent, impede their existing health care system; conservation and sustainable harvest of medicinal plants in the area are urgently needed.