Frontline Health Facilities Research Articles

Assessing public health sector performance in Bangladesh: Implications for health systems strengthening and universal health coverage - A secondary data analysis.

The Ministry of Health and Family Welfare has established a health systems strengthening initiative for measuring the performance of public sector health facilities in Bangladesh. The objective of the performance management initiative is to establish routine systems for measuring and scoring health facility performance and promote best practices in public health service management. The performance initiative includes a set of assessments conducted across the four tiers of the public health sector. The findings of assessments demonstrate improvements in the quality of health services and a sharp increase in the utilisation of services across all tiers during the period 2017-2019. The performance management initiative has also identified areas for improvement in the supply-side health system readiness, including ensuring an adequate supply of human resources, essential medicines, and functioning medical equipment and technologies. This initiative outlines the need to systematically address the issue of high health workforce vacancy rates through effective human resource planning and management strategies. The reporting of these ongoing health systems successes and challenges through the performance management initiative in Bangladesh provides an opportunity to develop evidence-based policy reforms for strengthening supply-side health systems. The initiative results, particularly in the context of growing public demand for services, also justifies a monitoring and evaluation mechanism focusing on the quality and coverage of frontline health facilities and the development of more integrated health systems. The performance management initiative will facilitate the maintenance of essential health services while addressing emergency health needs and tracking progress towards achieving the Universal Health Coverage goal.

Implementing Innovative Approaches to Improve Health Care Delivery Systems for Integrating Communicable and Non-Communicable Diseases Using Tuberculosis and Diabetes as a Model in Tanzania.

Background: Many evidence-based health interventions, particularly in low-income settings, have failed to deliver the expected impact. We designed an Adaptive Diseases Control Expert Programme in Tanzania (ADEPT) to address systemic challenges in health care delivery and examined the feasibility, acceptability and effectiveness of the model using tuberculosis (TB) and diabetes mellitus (DM) as a prototype. Methods: This was an effectiveness-implementation hybrid type-3 design that was implemented in Dar es Salaam, Iringa and Kilimanjaro regions. The strategy included a stepwise training approach with web-based platforms adapting the Gibbs' reflective cycle. Health facilities with TB services were supplemented with DM diagnostics, including glycated haemoglobin A1c (HbA1c). The clinical audit was deployed as a measure of fidelity. Retrospective and cross-sectional designs were used to assess the fidelity, acceptability and feasibility of the model. Results: From 2019-2021, the clinical audit showed that ADEPT intervention health facilities more often identified median 8 (IQR 6-19) individuals with dual TB and DM, compared with control health facilities, median of 1 (IQR 0-3) (p = 0.02). Likewise, the clinical utility of HbA1c on intervention sites was 63% (IQR:35-75%) in TB/DM individuals compared to none in the control sites at all levels, whereas other components of the standard of clinical management of patients with dual TB and DM did not significantly differ. The health facilities showed no difference in screening for additional comorbidities such as hypertension and malnutrition. The stepwise training enrolled a total of 46 nurse officers and medical doctors/specialists for web-based training and 40 (87%) attended the workshop. Thirty-one (67%), 18 nurse officers and 13 medical doctors/specialists, implemented the second step of training others and yielded a total of 519 additional front-line health care workers trained: 371 nurses and 148 clinicians. Overall, the ADEPT model was scored as feasible by metrics applied to both front-line health care providers and health facilities. Conclusions: It was feasible to use a stepwise training and clinical audit to support the integration of TB and DM management and it was largely acceptable and effective in differing regions within Tanzania. When adapted in the Tanzania health system context, the model will likely improve quality of services.

Strengths, disconnects and lessons in local and central governance of the response to the first wave of COVID-19 in Ghana.

To explore governance, coordination and implementation actors, structures and processes, facilitators, and barriers within local government and between central and local government in Ghana's COVID-19 response during the first wave of the outbreak. Cross-sectional single case study. Data collection involved a desk review of media, policy and administrative documents and key informant in-depth interviews. Two municipalities in the Greater Accra region of Ghana. Local government decentralised decision makers and officials of decentralised departments. None. None. Coordination between the national and local government involved the provision of directives, guidelines, training, and resources. Most of the emergency response structures at the municipal level were functional except for some Public Health Emergency Management Committees. Inadequate resources challenged all aspects of the response. Coordination between local government and district health directorates in risk communication was poor. During the distribution of relief items, a biased selection process and a lack of a bottom-up approach in planning and implementation were common and undermined the ability to target the most vulnerable beneficiaries. Adequate financing and equipping of frontline health facilities and workers for surveillance, laboratory and case management activities, transparent criteria to ensure effective targeting and monitoring of the distribution of relief items, and a stronger bottom-up approach to the planning and implementation of interventions need to be given high priority in any response to health security threats such as COVID-19. This work is funded by International Development Research Centre Grant No. 109479, Exploring and learning from evidence, policy and systems responses to COVID-19 in West and Central Africa.

Pulse oximetry and oxygen services for the care of children with pneumonia attending frontline health facilities in Lagos, Nigeria (INSPIRING-Lagos): study protocol for a mixed-methods evaluation

IntroductionThe aim of this evaluation is to understand whether introducing stabilisation rooms equipped with pulse oximetry and oxygen systems to frontline health facilities in Ikorodu, Lagos State, alongside healthcare worker...

Computer vision and machine learning for medical image analysis: recent advances, challenges, and way forward

The recent development in the areas of deep learning and deep convolutional neural networks has significantly progressed and advanced the field of computer vision (CV) and image analysis and understanding. Complex tasks such as classifying and segmenting medical images and localising and recognising objects of interest have become much less challenging. This progress has the potential of accelerating research and deployment of multitudes of medical applications that utilise CV. However, in reality, there are limited practical examples being physically deployed into front-line health facilities. In this paper, we examine the current state of the art in CV as applied to the medical domain. We discuss the main challenges in CV and intelligent data-driven medical applications and suggest future directions to accelerate research, development, and deployment of CV applications in health practices. First, we critically review existing literature in the CV domain that addresses complex vision tasks, including: medical image classification; shape and object recognition from images; and medical segmentation. Second, we present an in-depth discussion of the various challenges that are considered barriers to accelerating research, development, and deployment of intelligent CV methods in real-life medical applications and hospitals. Finally, we conclude by discussing future directions.

An Electronic Registry for Improving the Quality of Antenatal Care in Rural Bangladesh (eRegMat): Protocol for a Cluster Randomized Controlled Trial.

BackgroundDigital health interventions (DHIs) can alleviate several barriers to achieving better maternal and child health. The World Health Organization’s guideline recommendations for DHIs emphasize the need to integrate multiple DHIs for maximizing impact. The complex health system of Bangladesh provides a unique setting for evaluating and understanding the role of an electronic registry (eRegistry) for antenatal care, with multiple integrated DHIs for strengthening the health system as well as improving the quality and utilization of the public health care system.ObjectiveThe aim of this study is to assess the effect of an eRegistry with DHIs compared with a simple digital data entry tool without DHIs in the community and frontline health facilities.MethodsThe eRegMat is a cluster-randomized controlled trial conducted in the Matlab North and Matlab South subdistricts in the Chandpur district, Bangladesh, where health facilities are currently using the eRegistry for digital tracking of the health status of pregnant women longitudinally. The intervention arm received 3 superimposed data-driven DHIs: health worker clinical decision support, health worker feedback dashboards with action items, and targeted client communication to pregnant women. The primary outcomes are appropriate screening as well as management of hypertension during pregnancy and timely antenatal care attendance. The secondary outcomes include morbidity and mortality in the perinatal period as well as timely first antenatal care visit; successful referrals for anemia, diabetes, or hypertension during pregnancy; and facility delivery.ResultsThe eRegistry and DHIs were co-designed with end users between 2016 and 2018. The eRegistry was implemented in the study area in July 2018. Recruitment for the trial started in October 2018 and ended in June 2020, followed by an 8-month follow-up period to capture outcome data until February 2021. Trial results will be available for publication in June 2021.ConclusionsThis trial allows the simultaneous assessment of multiple integrated DHIs for strengthening the health system and aims to provide evidence for its implementation. The study design and outcomes are geared toward informing the living review process of the guidelines for implementing DHIs.Trial RegistrationISRCTN Registry ISRCTN69491836; https://www.isrctn.com/ISRCTN69491836International Registered Report Identifier (IRRID)DERR1-10.2196/26918

Healthcare Worker's Mental Health and Their Associated Predictors During the Epidemic Peak of COVID-19.

IntroductionThe outbreak of the coronavirus disease 2019 (COVID-19) poses an unprecedented challenge to healthcare workers (HCWs) globally. This study investigated potential factors related to depression, anxiety, and stress in a sample of Chinese HCWs during the peak of the COVID-19 epidemic.MethodsAn online survey was distributed to Chinese HCWs using respondent-driven sampling. Data were collected between February 13th and February 20th, 2020, immediately following the COVID-19 contagion peak in Hubei. A total of 1208 respondents were eligible for analysis. Mental health problems and social support were measured by the Depression Anxiety Stress Scales-21 (DASS-21) and the Perceived Social Support Scale (PSS).ResultsThe prevalence rates of depression, (DASS-depression > 9) anxiety (DASS-anxiety > 7) and stress (DASS-stress > 14) were 37.8%, 43.0% and 38.5%, respectively. Multivariate logistic regressions revealed that stress, anxiety, and depression were positively related to lower levels of social support, longer working hours, discrimination experience and workplace violence. The scarcity of medical equipment was correlated with increased stress and depression. Chinese HCWs working at COVID 19 designated hospitals were more likely to report anxiety. Additionally, volunteering to work in the frontline health facilities was inversely associated with depression.ConclusionMental health problems among Chinese HCWs were alarming during the peak of the COVID-19 epidemic. Health facilities require appropriate and standing services that address the mental health of healthcare workers, particularly during epidemic outbreaks.

A checklist to improve health system resilience to infectious disease outbreaks and natural hazards

Recent infectious disease outbreaks, including the ongoing global COVID-19 pandemic and Ebola in the Democratic Republic of the Congo, have demonstrated the critical importance of resilient health systems in safeguarding...

Producing routine malaria data: an exploration of the micro-practices and processes shaping routine malaria data quality in frontline health facilities in Kenya

BackgroundRoutine health information systems can provide near real-time data for malaria programme management, monitoring and evaluation, and surveillance. There are widespread concerns about the quality of the malaria data generated through routine information systems in many low-income countries. However, there has been little careful examination of micro-level practices of data collection which are central to the production of routine malaria data.MethodsDrawing on fieldwork conducted in two malaria endemic sub-counties in Kenya, this study examined the processes and practices that shape routine malaria data generation at frontline health facilities. The study employed ethnographic methods—including observations, records review, and interviews—over 18-months in four frontline health facilities and two sub-county health records offices. Data were analysed using a thematic analysis approach.ResultsMalaria data generation was influenced by a range of factors including human resource shortages, tool design, and stock-out of data collection tools. Most of the challenges encountered by health workers in routine malaria data generation had their roots in wider system issues and at the national level where the framing of indicators and development of data collection tools takes place. In response to these challenges, health workers adopted various coping mechanisms such as informal task shifting and use of improvised tools. While these initiatives sustained the data collection process, they also had considerable implications for the data recorded and led to discrepancies in data that were recorded in primary registers. These discrepancies were concealed in aggregated monthly reports that were subsequently entered into the District Health Information Software 2.ConclusionChallenges to routine malaria data generation at frontline health facilities are not malaria or health information systems specific; they reflect wider health system weaknesses. Any interventions seeking to improve routine malaria data generation must look beyond just malaria or health information system initiatives and include consideration of the broader contextual factors that shape malaria data generation.

\u201cThe number of clients is increasing but the supplies are reducing\u201d: provider strategies for responding to chronic antiretroviral (ARV) medicines stock-outs in resource-limited settings: a qualitative study from Uganda

BackgroundDespite the increasing frequency of ARV medicines stock-outs in Sub-Saharan Africa, there is little research inquiring into the mitigation strategies devised by frontline health facilities. Many previous studies have focused on ‘upstream’ or national-level drivers of ARVs stock-outs with less empirical attention devoted ‘down-stream’ or at the facility-level. The objective of this study was to examine the strategies devised by health facilities in Uganda to respond to the chronic stock-outs of ARVs.MethodsThis was a qualitative research design nested within a larger mixed-methods study. We purposively selected 16 health facilities from across Uganda (to achieve diversity with regard to; level of care (primary/ tertiary), setting (rural/urban) and geographic sub-region (northern/ central/western). We conducted 76 Semi-structured interviews with ART clinic managers, clinicians and pharmacists in the selected health facilities supplemented by on-site observations and documentary reviews. Data were analyzed by coding and thematic analyses.ResultsParticipants reported that facility-level contributors to stock-outs include untimely orders of drugs from suppliers and inaccurate quantification of ARV medicine needs due to a paucity of ART program data. Internal stock management solutions for mitigating stock-outs which emerged include the substitution of ARV medicines which were out of stock, overstocking selected medicines and the use of recently expired drugs. The external solutions for mitigating stock-outs which were identified include ‘borrowing’ of ARVs from peer-providers, re-distributing stock across regions and upward referrals of patients. Systemic drivers of stock-outs were identified. These include the supply of drugs with a short shelf life, oversupply and undersupply of ARV medicines and migration pressures on the available ARVs stock at case-study facilities.ConclusionHealth facilities devised internal stock management strategies and relied on peer-provider networks for ARV medicines during stock-out events. Our study underscores the importance of devising interventions aimed at improving Uganda’s medicines supply chain systems in the quest to reduce the frequency of ARV medicines stock-outs at the front-line level of service delivery. Further research is recommended on the effect of substituting ARV medicines on patient outcomes.

\u201cPractice so that the skill does not disappear\u201d: mixed methods evaluation of simulator-based learning for midwives in Uganda

BackgroundPostpartum hemorrhage and neonatal asphyxia are leading causes of maternal and neonatal mortality, respectively, that occur relatively rarely in low-volume health facilities in sub-Saharan Africa. Rare occurrence of cases may limit the readiness and skills that individual birth attendants have to address complications. Evidence suggests that simulator-based training and practice sessions can help birth attendants maintain these life-saving skills; one approach is called “low-dose, high-frequency” (LDHF). The objective of this evaluation is to determine the facilitating factors and barriers to participation in LDHF practice, using qualitative and quantitative information.MethodsA trial in 125 facilities in Uganda compared three strategies of support for LDHF practice to improve retention of skills in prevention and treatment of postpartum hemorrhage and neonatal asphyxia. Birth attendants kept written logs of their simulator-based practice sessions, which were entered into a database, then analyzed using Stata to compare frequency of practice by the study arm. The evaluation also included 29 in-depth interviews and 19 focus group discussions with birth attendants and district trainers. Transcripts were entered in Atlas.ti software for coding, then analyzed using content analysis to identify factors that motivated or discouraged simulator-based practice.ResultsPractice log data indicated that simulator-based practice sessions occurred more frequently in facilities where one or two practice coordinators helped schedule and lead the practice sessions and in health centers compared to hospitals. The qualitative data suggest that birth attendants who practiced more were motivated by a desire to maintain skills and be prepared for emergencies, external recognition, and establishing a set schedule. Barriers to consistent practice included low staffing levels, heavy workloads, and a sense that competency can be maintained through routine clinical care alone. Some facilities described norms around continuing education and some did not.ConclusionsDesignating practice coordinators to lead their peers in simulator-based practice led to more consistent skills practice within frontline health facilities. Ongoing support, scheduling of practice sessions, and assessment and communication of motivation factors may help sustain LDHF practice and similar forms of continuing professional development.Trial registrationRegistered with clinicaltrials.gov #NCT03254628 on August 18, 2018 (registered retrospectively).

Integrating innovations: a qualitative analysis of referral non-completion among rapid diagnostic test-positive patients in Uganda\u2019s human African trypanosomiasis elimination programme

BackgroundThe recent development of rapid diagnostic tests (RDTs) for human African trypanosomiasis (HAT) enables elimination programmes to decentralise serological screening services to frontline health facilities. However, patients must still undertake multiple onwards referral steps to either be confirmed or discounted as cases. Accurate surveillance thus relies not only on the performance of diagnostic technologies but also on referral support structures and patient decisions. This study explored why some RDT-positive suspects failed to complete the diagnostic referral process in West Nile, Uganda.MethodsBetween August 2013 and June 2015, 85% (295/346) people who screened RDT-positive were examined by microscopy at least once; 10 cases were detected. We interviewed 20 RDT-positive suspects who had not completed referral (16 who had not presented for their first microscopy examination, and 4 who had not returned for a second to dismiss them as cases after receiving discordant [RDT-positive, but microscopy-negative results]). Interviews were analysed thematically to examine experiences of each step of the referral process.ResultsPoor provider communication about HAT RDT results helped explain non-completion of referrals in our sample. Most patients were unaware they were tested for HAT until receiving results, and some did not know they had screened positive. While HAT testing and treatment is free, anticipated costs for transportation and ancillary health services fees deterred many. Most expected a positive RDT result would lead to HAT treatment. RDT results that failed to provide a definitive diagnosis without further testing led some to question the expertise of health workers. For the four individuals who missed their second examination, complying with repeat referral requests was less attractive when no alternative diagnostic advice or treatment was given.ConclusionsAn RDT-based surveillance strategy that relies on referral through all levels of the health system is inevitably subject to its limitations. In Uganda, a key structural weakness was poor provider communication about the possibility of discordant HAT test results, which is the most common outcome for serological RDT suspects in a HAT elimination programme. Patient misunderstanding of referral rationale risks harming trust in the whole system and should be addressed in elimination programmes.

The Great East Japan Earthquake: Analyses of Disaster Impacts on Health Care Clinics.

Local health facilities play a critical role in mitigating the deterioration of health after catastrophic disasters. However, limited information is available on clinic damage. Therefore, the National Institute of Public Health conducted surveillance on clinic damage after the 2011 Great East Japan Earthquake (GEJE) to identify risk factors. A cross-sectional study using a paper-based questionnaire was conducted that targeted 728 clinics located in coastal areas in the 3 prefectures most affected by the GEJE. The risk of building damage was inversely correlated with distance from the coast, whereas the risk of ceasing operations was significantly correlated with building damage and some specialties of clinics, namely, internal medicine and pediatrics.DiscussionIn mountainous countries like Japan, clinics often need to be built in coastal areas, where the majority of residents live. This surveillance revealed that clinics built in readily accessible locations and that provide care with high needs are more likely to get damaged by tsunamis. As clinics are often the frontline health facilities in disaster settings, local disaster plans need to include plans to reinforce disaster preparedness among clinics. For effective planning and resource allocation, nationwide hazard vulnerability analysis using a global standard will be helpful. (Disaster Med Public Health Preparedness. 2018; 12: 291-295).

Technical Efficiency in Public Health Facilities in Meru County: Dea Analysis

Background: Healthcare provision is one of the key strategic Development Goals to be achieved by the year 2030. Governments have directed a lot of financial resources towards this purpose in an effort to meet the threshold set out by the WHO to ensure provision of quality healthcare and access by all citizens. Objectives: To measure the technical efficiency levels in the public health system in Meru County in Kenya and investigate determinants of the technical efficiencies among the Decision Making Units (DMUs). Data analysis: Analysis reported in this paper is based on the data from Meru County health centres. It consisted of 17 Decision Making Units (DMUs) with inputs as clinical staff and other staff while outputs were maternal care visits and other visits. Dummy variables considered were; education, training, gender of head nurse and laboratory. Analysis was done by Data Envelopment Analysis (DEA). Results: The analysis revealed that average technical efficiency in the sample was 45.2%. This findings suggest that the existing health care services can be increased by up to 54.8% without providing additional resources to the frontline health facilities- a near replication of findings originally reported earlier. Tobit regression results show that gender of the facility manager and the availability of a laboratory at a facility are the main determinants of efficiency. Conclusion and recommendation: Policies designed to improve health care delivery should focus on upgrading laboratory services and skills of facility heads, especially managerial abilities of female nurses. Efforts need to be directed towards enhancing efficiency such as training staff in management practices, maintenance of laboratory equipment, gender composition of staff should equally be considered. Focus on preventive healthcare such as regular check-ups would lower risks of severe or resistant cases that are difficult to treat in order to increase efficiency. Creation of conducive waiting and smooth flow of patient cues in the health facility would also increase technical efficiency of the facility.

MPneumonia, an Innovation for Diagnosing and Treating Childhood Pneumonia in Low-Resource Settings: A Feasibility, Usability and Acceptability Study in Ghana.

Pneumonia is the leading cause of infectious disease mortality in children. Currently, health care providers (HCPs) are trained to use World Health Organization Integrated Management of Childhood Illness (IMCI) paper-based protocols and manually assess respiratory rate to diagnose pneumonia in low-resource settings (LRS). However, this approach of relying on clinical signs alone has proven problematic. Hypoxemia, a diagnostic indicator of pneumonia severity associated with an increased risk of death, is not assessed because pulse oximetry is often not available in LRS. To improve HCPs’ ability to diagnose, classify, and manage pneumonia and other childhood illnesses, “mPneumonia” was developed. mPneumonia is a mobile health application that integrates a digital version of the IMCI algorithm with a software-based breath counter and a pulse oximeter. A design-stage qualitative pilot study was conducted to assess feasibility, usability, and acceptability of mPneumonia in six health centers and five community-based health planning and services centers in Ghana. Nine health administrators, 30 HCPs, and 30 caregivers were interviewed. Transcribed interview audio recordings were coded and analyzed for common themes. Health administrators reported mPneumonia would be feasible to implement with approval and buy-in from national and regional decision makers. HCPs felt using the mPneumonia application would be feasible to integrate into their work with the potential to improve accurate patient care. They reported it was “easy to use” and provided confidence in diagnosis and treatment recommendations. HCPs and caregivers viewed the pulse oximeter and breath counter favorably. Challenges included electricity requirements for charging and the time needed to complete the application. Some caregivers saw mPneumonia as a sign of modernity, increasing their trust in the care received. Other caregivers were hesitant or confused about the new technology. Overall, this technology was valued by users and is a promising innovation for improving quality of care in frontline health facilities.

45 Persisting challenges in the provision of quality obstetric care to women with pre-eclampsia and eclampsia in nigeria: Assessment of health providers’ preparedness and facility readiness

Introduction In Nigeria, pre-eclampsia and eclampsia (PE/E) are leading causes of maternal and perinatal mortality and morbidity. Screening, early antenatal detection, and timely management are the most effective for preventing morbidity and mortality from these pregnancy-related disorders. Objective This study assessed the preparedness of frontline health care providers and facilities readiness for early detection and management of PE/E in seven states in Nigeria. Methods From each of the six geo-political zones in Nigeria, at least one state was selected for a landscape analysis on PE/E. In each study state, secondary and primary health care facilities were purposively selected and assessed in terms of provider knowledge, attitude and practice as well as availability of essential tools, drugs and commodities at facilities for the prevention, early detection and appropriate management of PE/E over a 3-month period (June to August, 2016). Three hundred and seventy-nine (379) health care providers and ninety-six (96) health facilities were assessed using a self- administered, semi-structured questionnaires. Data were entered using Epi Info and were exported to SPSS software for analysis. Results Providers’ knowledge on PE/E was grossly inadequate and skills were similarly lacking. Essential tools such as blood pressure measuring machines (sphygmomanometers and stethoscopes), urine dipsticks for rapid assessment of urine sample for significant proteinuria, drugs including magnesium sulphate (MgSO 4 ) and anti-hypertensives were not available in the majority of the facilities evaluated. Less than one third (31%) of all facilities had all the necessary equipment and supplies, a little more than one-third (34%) had MgSO 4 available in the labor and maternity units and less than one-fifth (19%) of all facilities had correct guidelines in place for managing PE/E, including for the administration of MgSO 4 . Only 12% and 10% of health care providers, respectively, knew the correct loading dose and maintenance doses of MgSO 4 , and none of the providers interviewed knew the blood pressure threshold for introducing anti-hypertensives in women with hypertensive disorders in pregnancy. Conclusions Reduction in PE/E-related mortality and morbidity hinges on health care providers’ ability to recognize PE/E and have essential tools and commodities available to manage cases; the current state of frontline providers’ knowledge and facility readiness would make this reduction near impossible. In order to improve health outcomes relating to PE/E, attention must be paid to the in-service training of frontline antenatal care providers (in Nigeria, these include nurses, midwives and community health extension workers). Similarly, health care facilities should be equipped with essentials tools and live-saving commodities for managing women with PE/E.

Preparedness Against an Influenza Pandemic of the Frontline Health Facilities in Southern Thailand

Preparedness at the frontline health level is essential for early detection, response, and prevention of the spread of an influenza pandemic in a community. This study aimed to assess and document patterns of basic preparedness for a threat of an influenza pandemic of the frontline health facilities in southern Thailand. A cross-sectional assessment was conducted among health centers. Key staffs were asked to complete a checklist consisting of facility access plan, surveillance, infection control, risk communication and health information dissemination, and health alert network and information technology. showed that the frontline health facilities were not well prepared for the threat in the early stages of a pandemic. Using cluster analysis, 6 variation patterns of preparedness were identified, with infection control being the weakest. Grassroots healthcare should be encouraged and supported to increase capacities in preparedness against influenza pandemics. Periodical monitoring by higher levels is needed.

Revolving drug funds at front-line health facilities in Vientiane, Lao PDR.

Pharmaceutical cost recovery programmes, which have been mainly implemented in Africa, are gradually spreading to Southeast Asian countries that formerly belonged to the socialist bloc. This report describes the economic and operational realities of revolving drug funds (RDFs) at district hospitals and health centres in the capital of the Lao PDR by reviewing research conducted by the implementing department. People in the municipality spent an average of US$11 on drugs in 1996. The RDFs comprised only 3% of the total yearly drug sales in the municipality, whereas private pharmacies accounted for 75%. The RDFs were forced to operate in conjunction with the remaining government drug endowment and the thriving private pharmacies. This scheme has provided a stable supply of essential drugs. The assurance of drug availability at the front-line health facilities has resulted in increased utilization of the facilities despite the introduction of a drug fee. The cost recovery rate was 107% at health centres and 108% at district hospitals in two monitored districts during the 10 months from November 1997. Decentralized financial management was essential for cost recovery, allowing timely adjustment of selling prices as purchase prices rapidly inflated after the Asian economic crisis. The health staff observed that the people perceived drugs as everyday commodities that they should buy and take based on self-diagnosis and personal preference. Adaptation of the public health authorities to market-oriented thinking along with the establishment of pharmaceutical cost recovery occurred with few problems. However, both financial and operational management capacity at the municipal level pose a major challenge to policy clarification and scheme setting, especially in procurement, control of prescribing practices and the integration of drug dispensing with other components of quality clinical care.

Improved survival of patients with homozygous familial hypercholesterolaemia treated with plasma exchange.

Plasma exchange was undertaken in five patients with homozygous familial hypercholesterolaemia at intervals of two weeks for a mean of 8.4 years. These patients had survived an average of 5.5 years longer than their five respective homozygous siblings (p = 0.3), each of whom must have had a matching genetic defect but who died untreated. The 37% decrease in peak serum cholesterol concentrations maintained by plasma exchange presumably reduced progression of atherosclerosis in the treated patients and thus lessened their risk of premature death.

Psychiatry in Japan's general hospitals: a brief report.

Although the Japanese Society of Neuropsychiatry advocated the development of psychiatric departments in general hospitals as long as thirty years ago, progress has been regrettably slow. While public health centers are legally the front-line mental health facilities in Japan, they have not fulfilled their function and perhaps have even impeded development of psychiatric services in general hospitals. In Tokyo City, only three outpatient psychiatry clinics and no inpatient services are available to 10,000,000 inhabitants in eight general city hospitals. The advantages of psychiatric services in general hospitals are apparent; further progress awaits public enlightenment, increased staff, and political and community support.