The cost of medical care and people's health-seeking behaviour before being suspected of tuberculosis in three local health systems, Nicaragua.

OBJECTIVE: To assess the medical costs incurred by users and delay between first contact with a care provider and sputum test for acid-fast bacilli (AFB) in three areas of Nicaragua. METHODS: Directed interviews of consecutive series of tuberculosis (TB) suspects whose sputum had been examined for AFB. RESULTS: Of 252 TB suspects interviewed, 52% used more than one type of care giver and 35% used private practitioners. As a consequence, 18%, 21% and 29% of the interviewees in Carazo, El Viejo and Matagalpa, respectively, spent more than 1 month of the country's median income per inhabitant on medical care between the first visit to a care provider and the first sputum examination. Furthermore, more than 3 months elapsed on that part of the care pathway for 30%, 17% and 3% of interviewees in Matagalpa, El Viejo and Carazo, respectively. CONCLUSION: This study sheds light on the costs and delays incurred by TB suspects before reaching a laboratory for sputum smear examination. Both costs are lower for those suspects who exclusively use first-line governmental health services (FLGHS). This has been relatively little documented in Latin America to date and could be used as an argument to develop strategies to strengthen the credibility of FLGHS.

Coping strategies of health personnel during economic crisis: A case study from Cameroon.

OBJECTIVES: Severe economic crisis compelled many governments in Sub-Saharan Africa to adopt structural adjustment programmes. This was accompanied by price increases and cuts in the salaries of civil servants. We explored how health personnel in one province of Cameroon coped with this situation, and what the perceived effects on service quality were. METHODS: Key informant and focus group interviews with government and mission (church) health personnel; interviews with service users to validate the findings. RESULTS: Government health personnel had experienced larger cuts in salaries than their mission counterparts; they no longer received allowances and incentives still available to mission personnel and appeared more demotivated. Most government and mission personnel reported legal after-hours income raising activities. Government personnel frequently reported additional 'survival strategies' such as parallel selling of drugs, requesting extra charges for services, and running private practices during work hours. There was a high level of self criticism among government personnel indicating a dissonance between their attitude and practices. They considered these practices negative and harmful for service users. CONCLUSION: Remedial action is urgent. Options include reinstating allowances for good performance and ensuring regular supervision without blaming individual health workers for problems caused by the state of the health system.

[Decentralization of the tuberculosis campaign and its follow-up in the Dosso Department (Niger)]. / La décentralisation de la lutte antituberculeuse et son suivi dans le Département de Dosso (Niger).

The national program for tuberculosis control has been decentralized in the dispensaries of Dosso Department since 1985. The physician appointed as departmental coordinator at the Departmental Center for Tuberculosis has organized training and ensured a close follow-up of the activities through supervision and valuation. In spite of an important decentralization and an increase of the sputum examinations, the case detection has not been improved (mean detection rate equals to 0.28/1000. In opposite, the cure rate has been increased appreciably (from 24% to 52%) and the noncompliers rate has decreased (from 42% to 19%). The follow-up of the program has got important side benefits on the other activities. The efficiency of the decentralization and of the follow-up is discussed, the costs of the start and use have been estimated. It has been recommended to integrate the program to the other health activities and to delegate the follow-up to the physicians in change in the Medical Center.