Reduce Service Costs Research Articles

The impact of electronic medical records' functions on the quality of health services

Background/aims Electronic medical records are the most common E-health application and they are starting to be implemented worldwide. In Jordan, the introduction of electronic medical records helps to improve quality and reduce service costs. This article aimed to examine how the implementation of electronic medical records impacted health service quality in Jordan. Methods A cross-sectional study was conducted in Jordanian hospitals that used electronic medical records. The data were collected using a self-administered questionnaire, which 582 healthcare professionals returned. The Statistical Package for Social Sciences was used to perform descriptive and statistical analyses. Results The results showed that there was a statistically significant impact when using electronic medical records. These findings were divided into two categories: function (practice management, communication, documentation or data entry, and medication management) and on the quality of services (reliability, responsiveness, assurance, and empathy). Conclusions The research indicated that using electronic medical records improved the quality of health services.

Customer stratification theory and value evaluation—analysis based on improved RFM model

Scientific customer stratification method can help enterprises identify valuable customers, thus effectively improving the operating profit of enterprises. However, current customer stratification methods have not considered the impact of cost to service (CTS) on customer value (such as the RFM model). In this paper, K-mean clustering method is adopted to classify customers into four categories, namely 1) the most valuable customers, 2) valuable customers, 3) general customers and 4) customers with low contribution. By adding a new evaluation dimension of CTS, the original RFM model is improved. In this way, the RFMC model is built and can provide more comprehensive evaluation on customer value. Finally, the results show that the addition of CTS index significantly changes the clustering results of the original RFM model and the overall consideration of consumption amount and CTS truly reflect the customer value. Thus, the improved RFMC model optimizes the results of customer stratification and it can effectively sort out the valuable customers for enterprises. Enterprises will be more dedicated to serving the valuable customers so as to maximize profits and reduce service costs of customers with lower value to make up for profit losses.

A Super Simple Life-cycle Cost Estimation Model with Minimum Data Requirement

Life-cycle costing is a practical approach to estimate the total cost of ownership in product-service systems. In high-value manufacturing sectors, due to the complication of overhaul invoices, shop visits, repair and maintenance interventions, identifying service cost reduction opportunities can be complex. Moreover, quantifying the impact of key cost drivers on the total cost is challenging due to the lack of complete historical data and high level of uncertainties within the service cost data. To address these challenges, a super simple life-cycle cost model architecture is presented. A set of minimum data requirements is identified for the development of the presented cost model. The model architecture comprises of life-cycle cost breakdown structure and work breakdown structure to specify the cost drivers, unit costs and their frequencies. A bottom-up activity-based cost estimation approach is implemented to calculate the total life-cycle cost of a product. The way that the minimum data requirement is applied to the cost estimation structure is explained. In addition, the minimum data is employed to perform a deterministic sensitivity analysis to compare the relative impact of the model input on the total cost. The Monte-Carlo simulation is performed for estimating the uncertainty propagation on the total life-cycle cost. The presented model architecture simplifies life-cycle cost estimations and service control decisions for maintenance, repair, and overhaul actions. A case study of life-cycle cost estimation in the machine tool industry is considered for testing the validity of the cost model architecture.

O Conceito de Gestão por Processos Aplicado à Administração Legal

This paper aims to identify the key business processes that are part of the organization structure in law firms that provide legal services. The study was conduct within the legal administration and business process management approaches. A qualitative-exploratory and quantitative-descriptive research was realized. The first, conducted through the application of semi-structured individual interviews, identified eight theoretical dimensions that were used in the latter, as a reference for defining the research questionnaire. Seven law firms certified by ISO 9001 were used for the identification of business processes. As results the identified processes were grouped according to APQC Process Classification Framework, in four key process (vision and strategy development, service market, products and services distribution and customer service management). Also, six support process categories were identified: information technologies management, financial resources management, acquiring, constructing and management properties, environmental health and safety, external relationships management and management knowledge, improvement, and change. Providing greater customer satisfaction has been identified as the main factor for the offices to map their business processes, while lesser degree of importance was attributed to product and service cost reduction and quality improving.

Adoption of Hospital Information Systems in Public Hospitals in Turkey: An Analysis with the Unified Theory of Acceptance and Use of Technology Model

Information and communication technologies (ICTs) has become a tool which cannot be ignored in terms of public administrations, which provides advantage to the administrations as far as they can be adapted. The use of ICTs become widespread in the health sector as it is in all other sectors. In hospitals, hospital information systems (HIS) are used to keep records of patients and hospitals securely, to improve appointment, in-hospital management, decision support and workflow processes. Therefore, HISs are also used to increase efficiency and productivity, to reduce error rates, to increase service quality, to reduce service costs and to realize the specific purposes such as ensuring patient satisfaction. It is necessary that the end users should adopt HISs to obtain the expected benefits and to implement HIS successfully in public hospitals. The adoption of a technology product is also a sociological phenomenon at the same time. In this regard, the issue of adoption in the relevant literature is addressed in the context of a wide variety of models and many variables. This study is also a study of technology adoption. The subject of the study is the adoption of HISs in public hospitals in Turkey. In this context. The study aimed to determine the factors affecting the adoption of HISs by the personnel working in public hospitals in Turkey, in accordance with the Unified Theory of Acceptance and Use of Technology (UTAUT) model in the literature on technology adoption. In the study, the universe of the study consisted of the personnels (physicians, nurses, health officers, medical secretaries] which were working in public hospitals in the Bursa and Balıkesir Metropolitan Municipalities at the time of the study. According to the results of the study, performance expectancy, effort expectancy and social influence variables have positive and significant effects on the behavioral intention of hospital staff for using of HISs. In addition, facilitating conditions and behavioral intention variables have a positive and significant effect on usage behavior. On the other hand, it was found that gender has a moderator effect on the relationship between performance expectancy, effort expectancy and behavioral intention. Experience has a moderator effect on the relationship between the social influence and the behavioral intention while age has a moderator effect on the relationship between facilitating conditions and use behavior.

Making Hard Choices in Local Public Health Spending With a Cost-Benefit Analysis Approach.

Background: In 2013, public health moved into Local Authorities, but initial optimism has been overtaken by serious ongoing financial constraints and an uncertain future. Hard choices have become an everyday reality across local authorities and for their public health teams. Assessing the return-on-investment of public health interventions and possessing economic evaluation skills have become more critical than ever before.Methods: Using the New Economy cost-benefits-analysis model developed at the Greater Manchester Combined Authority, we undertook cost benefit analyses of some of our largest areas of commissioned spend in local public health practice to better understand both the public and fiscal returns of our interventions.Results: The cost-benefit analyses indicated considerable variation in the public (economic and social) returns-on-investment for our spend on services purchased as a commissioner with £1.37 to 6.81 returned for every £1 spent, and a fiscal return for every £1 invested of between £0.54 and 1.37. Additionally, the fiscal benefits (reduced service costs) of these public health interventions appear to primarily flow to the NHS, which accounts for about 94% of the fiscal return.Conclusion: While cost-benefit modeling cannot provide a complete picture of “value,” it does provide decision-makers with a transparent metric that facilitates a whole-of system discussion on “intervention value” and prevention at scale investments. This approach will support investment strategies when implementing Sustainability and Transformation Partnerships and Integrated Care Systems. However, these tools should be used to support robust decision-making processes, not as a replacement for or a short-circuiting of existing processes.

Vibration-based Condition Monitoring of Heavy Duty Machine Driveline Parts: Torque Converter, Gearbox, Axles and Bearings

As more features are added to the heavy-duty construction equipment, its complexity increases and early fault detection of certain components becomes more challenging due to too many fault codes generated when a failure occurs. Hence, there is a need to complement the present onboard diagnostics method with a more reliable diagnostics method for adequate condition monitoring of the heavy-duty construction equipment in order to improve uptime. Major components of the driveline (such as the gearbox, torque converter, bearings and axles) are components necessary to monitor. A failure among any of these major components of the driveline may result in the machine standing still until a repair is scheduled. In this paper, vibration based condition monitoring methods are presented with the purpose to provide a diagnostic framework possible to implement onboard for monitoring of critical driveline parts in order to reduce service cost and improve uptime. For the development of this diagnostic framework, sensor data from the gearbox, torque converter, bearings and axles are considered. Further, the feature extraction of the data collected has been carried out using adequate signal processing methods, which includes: Adaptive Line Enhancer and Order Power Spectrum respectively. In addition, Bayesian learning was utilized for adaptive learning of the extracted features for deviation detection. Bayesian learning is a powerful prediction method as it combines the prior information with knowledge measured to make updates. The results indicate that the vibration properties of the gearbox, torque converter, bearings and axle are relevant for early fault detection of the driveline. Furthermore, vibration provides information about the internal features of these components for detecting deviations from normal behavior. In this way, the developed methods may be implemented onboard for the continuous monitoring of these critical driveline parts of the heavy-duty construction equipment. Thus, if their health starts to degrade a service and/or repair may be scheduled well in advance of a potential failure and in that way the downtime of a machine may be reduced and costly replacements and repairs avoided

Cyber Defense Maturity Levels and Threat Models for Smart Cities

Smart cities are in development around the world to tackle urbanization challenges. Smart solutions are being developed to optimize scarce resources, reduce service cost, improve service quality and improve the livelihood of city residents. With smart city infrastructure getting digitized and remotely accessible, the risk of cyber security cannot be overlooked. This article describes the technical and non-technical challenges smart cities are facing with regards to cyber security attacks. The article outlines design requirements that should be considered when designing a secure smart city. The requirements are overarching technical, operational, social, safety, legal and usability domains. In addition, the article proposes cyber defense maturity levels for smart cities and describes threat models relevant to each maturity level.

Skin shop: A new model for high-volume skin cancer care

Non-melanoma skin cancer incidence is increasing in New Zealand. Increased cost of care has led to service pressure and a review of models of care. A high-volume skin surgery service at Waikato Hospital has been developed to reduce service costs. This study examines the oncological safety of the new model. Prospective data for all skin lesions excised were collected from December 2014 to December 2016. Primary outcomes were rate of complete excision, rate of incomplete excision and rate of narrow excision. A total of 2076 lesions were excised: 92% were complete, 4.2% were narrow and 3.2% were incomplete. The rate of narrow and incomplete excisions was low in a service delivered by supervised surgical registrars. The Skin Shop model is safe, inexpensive and suitable for adaptation to safely reduce the cost of skin cancer surgery.

Predictors and trajectory of performance status in patients with advanced cancer: A secondary data analysis of the international European Palliative Care Cancer Symptom study

Background: Performance status, a predictor of cancer survival, and ability to maintain independent living deteriorate in advanced disease. Understanding predictors of performance status trajectory could help identify those at risk of functional deterioration, target support for independent living and reduce service costs. The relationship between symptoms, analgesics and performance status is poorly delineated. Aim: The aim of this study is to determine whether demographics, analgesics, disease characteristics, quality-of-life domains and C-reactive protein predict the trajectory of Karnofsky Performance Status (KPS) in patients with advanced cancer. Design: The study design is the secondary data analysis of the international prospective, longitudinal European Palliative Care Cancer Symptom study (ClinicalTrials.gov: NCT01362816). A multivariable regression model was built for KPS area under the curve per day (AUC). Setting and participants: This included adults with advanced, incurable cancer receiving palliative care, without severe cognitive impairment and who were not imminently dying (n = 1739). Results: The mean daily KPS AUC (n = 1052) was 41.1 (standard deviation = 14.1). Opioids (p < 0.001), co-analgesics (p = 0.023), poorer physical functioning (p < 0.001) and appetite loss (p = 0.009) at baseline were explanatory factors for lower KPS AUC. A subgroup analysis of participants with C-reactive protein data (n = 240) showed that only C-reactive protein (p = 0.040) and physical function (p < 0.001) were associated with lower KPS AUC. Conclusion: This study is novel in determining explanatory factors for subsequent functional trajectories in an international dataset and identifying systemic inflammation as a candidate therapeutic target to improve functional performance. The effect of interventions targeting physical function, appetite and inflammation, such as those used for cachexia management, on maintaining functional status in patients with advanced cancer needs to be investigated.

The improvement of thermal characteristics of autoclave aerated concrete for energy efficient high-rise buildings application

Nowadays, the problem of energy saving is very relevant. One of the ways to reduction energy consumption in construction materials production and construction of civil and industrial high-rise buildings is the application of claddings with heat-insulating performance. The concept of energy efficiency of high-rise buildings is closely related to environmental aspect and sustainability of applied construction materials; reducing service costs; energy saving and microclimate comfortability. A complexity of architectural and structural design as well as aesthetic characteristics of construction materials are also should be considered. The high interest focused on materials with combined properties. This work is oriented on the study of energy efficiency of buildings by improving heat-insulation and strength performance of autoclave aerated concrete. The applied method of sulfate activation of lime allows monitoring phase and structure formation in aerated concrete. The optimal mix design of aerated concrete with the compressive strength up to 8.5 MPa and decreased density up to 760 kg/m3 was proposed. Analysis of structure at macro-and microscale was performed as well as the criteria of an optimal porosity formation was considered a number, size, shape of pore and density of interior partition. SEM analysis and BET method were performed in this research work. The research results demonstrated the correlation between structure and vapor permeability resistance, also it was found that the increase of strength can lead to reduction of thermal conductivity.

한국 ETF 시장의 시스템적 리스크 분석 및 최적의 ETF 도입 순서에 대한 연구

Traditionally, the private wealth management industry has been dedicated to high-net-worth individuals due to expensive service costs. However, robo-advisors are making sudden rises during the on-going FinTech revolution. Robo-advisors aim to provide personalized wealth management services for everyone by using automated investment management algorithms and online distribution channels. To reduce service costs, robo-advisors mainly use ETFs to construct investment portfolios. Therefore, Korean ETF market should grow in both quantity and quality, in order for robo-advisors to succeed in Korea. In this study, we first analyze how vulnerable the Korean ETF market is to external or internal shocks in comparison with the U.S. ETF market. Then, we derive the optimal introduction sequence of ETFs in the Korean ETF market based on the modern portfolio theory.

PENSAMENTO ENXUTO APLICADO A CANTEIROS DE OBRA DE PROJETOS INDUSTRIAIS

Lean thinking may be understood as a concept based on the continuous search for the model ofproducing more with less. In other words, identifying opportunities for improving productivity and reducingcosts. This concept has been widely applied in manufacturing and, in a smaller scale, at office environments.However, it seems uncommon at construction sites of industrial projects, thus opening the pathway for thisresearch paper. For that purpose, we selected an integrated steelmaking plant located in the southeast regionof Brazil, which gathers all required conditions to map, analyze, and identify opportunities for improvingthe implementation of industrial projects. At this moment we applied the concept of projects management aswell as engineering of methods and time, which revealed an opportunity for increasing the effective workingtime at the construction sites of the projects studied herein, due to the elimination of wasted time in severalsteps of the work flow. The results of this research showed that 10% of the daily effective working timegain corresponding to 59 minutes/day, would represent 4% in the cost reduction of services.

27 Functional neurological presentation: a psychological intervention

<h3>Objective</h3> To reduce a significant functional tremor for a patient who has been diagnosed with a trauma response to life events, who’s medical conditions are exacerbated by the extreme and persistent nature of the tremor and the complex psychological vulnerability of JM. Intentions of Neuropsychology Services • Improve well-being; • Reduction in functional movement; • Reduction in associated pain; • Reduction in presentation to clinical services; • Reduction in annual cost of services used by patients: • Greater engagement and functioning in society; • Improved QOL. <h3>Method</h3> <h3>Therapy part one</h3> <h3>Attendance</h3> 1. Education Day for JM and his partner, and one other friend or family member completed Clinicians at the education day will include an 8 c Clinical Psychologist and an 8b Counselling Psychologist. JM, his partner, and family member attended a course/workshop lasting one session/two hours They are offered prescriptive education around the evidence for cause and treatment of Functional Neurological Presentations. This included prevalence rates, theories and evidence, the process of diagnosis e.g., how the person came to be in the Neuropsychology Service, investigations that were carried out by the specialists involved, and the individual formulation for JM was provided and explored and was presented to JM and others. Questions and answers and discussion points were informally discussed and shared. <h3>Therapy part two</h3> *A therapeutic package of 10–14 sessions was offered *liaison with family is on-going over the period of therapy JM and others indicated that they wished to explore the formulation through therapy • Outcome measures were completed 2. Therapy consultation Formulation discussion JM has a consultation with a psychologist and a counselling psychologist/hypnotherapist and an agreement was made regarding their be-spoke service: Psychodynamic therapy Or CBT/solution focused interpersonal therapy/hypnotherapy *JM and others explored and agreed an approach CBT/Hypnotherapy in addition to the education sessions <h3>Therapy part three</h3> 3. Treatment sessions Treatment sessions will be carried out by the 8 c Clinical Psychologist and the Counselling Psychologist in unison at JM home in West Sussex. Following Two DNAs whether cancelled sessions or non-attended sessions will result JMs discharge, unless there are clear and exceptional circumstances. The 8 c will make a decision on each individual case. Each session will be taped to aid memory, for reflection and homework over the we. <h3>Therapy part four: end of therapy</h3> *Penultimate session: • Outcome measures to be completed • Satisfaction questionnaire completed • Consent to audit financial elements of care Last session • Exit Meeting Following last session • Discharge report *the approach may or may not involve other friends or family. *the approach has an end of therapy exit meeting attached to the last 30 min of the final session. OUTCOME MEASURES may include: Consent Forms Equality and Diversity forms Risk assessment BICRO-39 Well-being questionnaire QOL questionnaire DASS42 (mood measure) Beck measures (where needed) Self-esteem measures (where needed) PTSD measures (where needed) Consent for Audit data collection (clinical and financial) Behavioural data Video data of movement Measure of pain Measure of pain <h3>Results</h3> We are at session 4 and will have the end of therapeutic contract meeting in January. The outcome of this therapeutic approach will be evaluated at this time. <h3>Conclusion</h3> Conclusions as to the effectiveness of the intervention will be evaluated via the behavioural data and the outcome measures. We will also seek feedback from the treating Neuropsychiatric Team at St Georges in London.

Bottom-up framework for cost allocation to services in telecommunication networks

Communications service providers (CSP) supply information, transport and passive infrastructure services that rely on the deployment of multiservice networks. To attain service cost reductions, the planning and design of those networks is essential, so that the total cost of the network ownership (TCO) is minimized. In this paper, we propose a bottom-up calculation framework for the allocation of the TCO cost components (i.e. capital and operational expenditures) to the services supplied by a CSP. For this, the framework is formulated within the context of the network life-cycle. Our method provides the level of abstraction required for the calculation of the three basic service cost contributors, namely, direct, shared and common costs. Moreover, it outlines the role of network planning in the design of an efficient network infrastucture, and in the calculation of the TCO. Based on this, we show how the stand alone, fully allocated and long-run incremental costs of a service can be calculated. Besides the determination of service cost drivers, the framework is useful to evaluate the cost-efficiency of competing technologies. To illustrate this, we study the allocation of the infrastructure costs for a CSP offering transport services with an optical network. By designing the infrastructure with fixed-grid and flex-grid technologies, it is shown that in both cases the main service cost driver is determined by the transponders installed. The results show that fixed-grid fits well for the provisioning of high speed constant bit-rate transport services, whereas flex-grid is a good candidate for transport services with bursty traffic patterns.

Leveraging Frontline Employees’ Small Data and Firm-Level Big Data in Frontline Management

The advent of new forms of data, modern technology, and advanced data analytics offer service providers both opportunities and risks. This article builds on the phenomenon of big data and offers an integrative conceptual framework that captures not only the benefits but also the costs of big data for managing the frontline employee (FLE)-customer interaction. Along the positive path, the framework explains how the “3Vs” of big data (volume, velocity, and variety) have the potential to improve service quality and reduce service costs by influencing big data value and organizational change at the firm and FLE levels. However, the 3Vs of big data also increase big data veracity, which casts doubt about the value of big data. The authors further propose that because of heterogeneity in big data absorptive capacities at the firm level, the costs of adopting big data in FLE management may outweigh the benefits. Finally, while FLEs can benefit from big data, extracting knowledge from such data does not discount knowledge derived from FLEs’ small data. Rather, combining and integrating the firm’s big data with FLEs’ small data are crucial to absorbing and applying big data knowledge. An agenda for future research concludes.

Content-aware replica placement strategy for IPTV services over peer-service area architecture

Due to the enormous improvement in networking and multimedia, IPTV has become recently a popular means to distribute high quality TV services over IP networks. Accordingly, Telecommunication companies started the competition to provide IPTV services to increase their customer base and profit. The key concern of service providers in this hectic competition is to provide high quality service with lower cost. However, the contents' popularity and the users' preferences are fluctuated rapidly, which leads to resources waste and load imbalance. Thus, the contents' status should be considered during the content replication to save resources and reduce service cost. To the best of our knowledge, there is no work investigate the impact of contents' status on building Replica Placement Strategy. Therefore, this paper studies the impact of contents' status on replica placement strategy over the peer-service area architecture. Two optimization models are proposed Cost Effective Model (CE), which replicates the contents partially without considering contents' status and Cost Effective with Load Balance model (CELB), which considers the contents' status. Both models have been solved using Hybrid Genetic Algorithm. The experimental results show that CELB model outperforms the other models in terms of Storage Saving Ratio (SSR), load distribution, and allocation cost.

Exploring the context in which different close-to-community sexual and reproductive health service providers operate in Bangladesh: a qualitative study.

BackgroundA range of formal and informal close-to-community (CTC) health service providers operate in an increasingly urbanized Bangladesh. Informal CTC health service providers play a key role in Bangladesh’s pluralistic health system, yet the reasons for their popularity and their interactions with formal providers and the community are poorly understood. This paper aims to understand the factors shaping poor urban and rural women’s choice of service provider for their sexual and reproductive health (SRH)-related problems and the interrelationships between these providers and communities. Building this evidence base is important, as the number and range of CTC providers continue to expand in both urban slums and rural communities in Bangladesh. This has implications for policy and future programme interventions addressing the poor women’s SRH needs.MethodsData was generated through 24 in-depth interviews with menstrual regulation clients, 12 focus group discussions with married men and women in communities and 24 semi-structured interviews with formal and informal CTC SRH service providers. Data was collected between July and September 2013 from three urban slums and one rural site in Dhaka and Sylhet, Bangladesh. Atlas.ti software was used to manage data analysis and coding, and a thematic analysis was undertaken.ResultsPoor women living in urban slums and rural areas visit a diverse range of CTC providers for SRH-related problems. Key factors influencing their choice of provider include the following: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect and familiarity. Informal providers are usually the first point of contact even for those clients who subsequently access SRH services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding SRH services.ConclusionTraining informal CTC providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality SRH (and other) care at the community level.

Economic Evaluation of the effect of Quitting Smoking on Weight Gains: Evidence from the United Kingdom

ObjectiveThis article estimated the causal effect of quitting smoking on body weight gains in the United Kingdom to evaluate whether savings in health costs deriving from smoking prevention and its related diseases are greater than the costs associated with increased obesity. MethodsWe used a longitudinal data set extracted from two waves (2004–2006) of the British Household Panel Survey, which includes information on smoking and a large number of sociodemographic variables. We modeled the effect of quitting smoking on body weight accounting for heterogeneous responses from individuals belonging to different clinical classes of body mass index (BMI) (i.e., overweight and obese individuals). National Health Service costs associated with smoking were then used to implement a cost-benefit analysis, comparing the advantages of smoking reductions with the costs associated with increased obesity. ResultsThe BMI was found to increase by 0.26 points for quitters compared with those who continued to smoke. The estimated BMI increase was larger for overweight (0.49 points) and obese (0.76 points) people. This result does not change when different control groups are examined. From an economic perspective, the National Health Service cost reductions attributable to quitting smoking were £156.81 million whereas the lost benefit for unintended increases in body weight was £24.07 million. ConclusionsThis article found that the health benefits associated with quitting smoking are greater than the costs associated with increased overweight and obesity.

Sistema de información de la red nacional de laboratorios de salud pública en el Perú (NETLAB)

Clinical laboratory information systems produce improvements in the quality of information, reduce service costs, and diminish wait times for results, among other things. In the construction process of this information system, the National Institute of Health (NIH) of Peru has developed and implemented a web-based application to communicate to health personnel (laboratory workers, epidemiologists, health strategy managers, physicians, etc.) the results of laboratory tests performed at the Peruvian NIH or in the laboratories of the National Network of Public Health Laboratories which is called NETLAB. This article presents the experience of implementing NETLAB, its current situation, perspectives of its use, and its contribution to the prevention and control of diseases in Peru.