Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania.

OBJECTIVE: To describe geographical patterns of implementation of the Integrated Management of Childhood Illness (IMCI) strategy in three countries and to assess whether the strategy was implemented in areas with the most pressing child health needs. METHODS: We conducted interviews with key informants at the national and district levels in Brazil, Peru and the United Republic of Tanzania, and an ecological study of factors associated with health worker training in IMCI. Explanatory factors included district population, distance from the capital, human development index, other socioeconomic indicators and baseline mortality rates in children younger than five years. FINDINGS: In line with recommendations by WHO, early implementation districts were characterized by proximity to the capital and suitable training sites, presence of motivated health managers and a functioning health system. In the expansion phase, IMCI tended to be adopted by other districts with similar characteristics. In Brazil, uptake by poor and small municipalities and those further away from the state capital was significantly lower. In Peru, there was no association with distance from Lima, and a non-significant trend for IMCI adoption by small and poor departments. In the United Republic of Tanzania, the only statistically significant finding was a lower uptake by remote districts. Implementation was not associated with baseline mortality levels in any country studied. CONCLUSION: Whereas clear and reasonable guidelines are provided for selection of early use districts, no criteria for promoting IMCI expansion had been issued, and areas of greatest need were not prioritized. Equity analyses based on the geographical deployment of new programmes and strategies can contribute to assessing whether they are reaching those who need them most.

Avaliação hemodinâmica da prótese heteróloga Biocor / Hemodynamic evaluation of Biocor heterologous prosthesis

Sao apresentados os resultados do estudo hemodinamico em 16 pacientes portadores de 18 proteses Biocor (porcina, com orificio modificado, preservadas em glutaraldeido).Em 4 casos, o debito cardiaco e os gradientes foram medidos antes e apos exercicio. Em 8 pacientes com protese mitrais, a pressao venocapilar media caiu de 28,9 +/- 6,1 mmHg para 13,3 +/- 4,2 mmHg pos - operatorio e as proteses apresentaram um gradiente final diastolico medio de 0,8 mmgH. Seis pacientes tinham proteses aorticas, com gradiente medio de 6 mmgH. Dois pacientes com dupla protese, apresentaram bons resultados em relacao a valvula mitral e gradientes de 29 e 48 mmHg nas valvulas aorticas (ambas numero 23). Conclui-se que as valvulas Biocor apresentaram bom desempenho hemodinamico, com ausencia de gradientes na maioria dos pacientes estudados, boa abertura dos folhetos, sem refluxos significativos