A realistic approach to the evaluation of the quality management movement in health care systems: a comparison between European and African contexts based on Mintzberg's organizational models.

The quality movement is gaining momentum worldwide in the field of health care. Initiated in industrialized countries, it steadily grows in Africa. However, there is no evidence that approaches designed to address issues in a given organizational context have the same effect in another one where issues present differently. Along the epistemological paradigm of realistic evaluation proposed by Pawson and Tilley, we use Mintzberg's organizational models to compare the configurations of European and African health care organizations and the trends followed by the quality management movement in both contexts. We illustrate how European health systems traditionally emphasize professional autonomy while African health systems are structured as command and control hierarchical systems. We illustrate how the quality movement in Europe emphasizes standardization of procedures, a characteristic of a mechanistic organization, while excessive standardization is part of the quality problem in Africa. We suggest that instilling professionalism may be a way forward for the quality movement in Africa to improve patient focus and responsiveness of responsible professionals. We also suggest that our interpretation of broad trends and contrasts may be used as a useful departure point to study the wide contextual diversity of the African experience with quality management.

[Sleeping sickness in the region of the town of Kinshasa: a retrospective analysis during the surveillance period 1996-2000]. / La maladie de sommeil dans la région Ville de Kinshasa: une analyse rétrospective des données de surveillance sur la période 1996-2000.

In the Democratic Republic of Congo, the re-emergence of sleeping sickness is no longer limited to rural areas. Over the course of the past decade, more and more cases have been reported from urban centres such as Kinshasa, Mbuji-mayi, Matadi and Boma. This paper presents a retrospective analysis on the region of Kinshasa over the period 1996-2000, using epidemiological surveillance, individual case files and available entomological data. There are 22 health districts in total; they were classified as urban when the population exceeded 5000 per square kilometre. The Human African Trypanosomiasis (HAT) control programme reported 2451 parasitologically confirmed new cases between 1996 and 2000, in the entire region of Kinshasa. Affected people (66%) were aged 15-49 years. Cases occurred in every health district, and 956 (39%) occurred in urban residents. Glossina captures in 1999 established the presence of Trypanosoma spp. Local HAT transmission is plausible but not proven. The high number of urban cases necessitates development of control strategies adapted to cities.

Monitoring unmet obstetric need at district level in Morocco.

Unmet obstetric need was assessed in Taounate province (Morocco) during the year 1995 by monitoring rates of major obstetric intervention for absolute maternal indications. We report results in terms of spatial distribution of the failures of the health care system to provide women with essential emergency obstetric care. An estimated 135 women with life-threatening conditions did not benefit from the obstetric interventions they required. The paper documents the effects of the monitoring process on the way the provincial team changed their way of dealing with deliveries. Assessment of unmet obstetric need in Taounate province proved feasible and affordable without external budgetary inputs. It provided the team with information on the magnitude of a previously ignored problem. The results were so dramatic as to lead the team to look for causes and solutions. These were clearly not merely technical but systemic in nature.

A health insurance scheme for hospital care in Bwamanda District, Zaire: lessons and questions after 10 years of functioning.

A voluntary insurance scheme for hospital care was launched in 1986 in the Bwamanda District in northwest Zaire. The paper briefly reviews the rationale, design and implementation of the scheme and discusses its results and performance over time. The scheme succeeded in generating stable revenue for the hospital in a context where government intervention was virtually absent and external subsidies were most uncertain. Hospital data indicate that hospital services were used by a significantly higher proportion of insured patients than uninsured people. The features of the environment in which the insurance scheme thrived are discussed and the conditions that facilitated its development reviewed. These conditions comprise organizational-managerial, economic-financial, social and political factors. The Bwamanda case study illustrates the feasibility of health insurance-at least for hospital-based inpatient care-at rural district level in sub-Saharan Africa, but also exemplifies the managerial and social complexity of such financing mechanisms.

A prepayment scheme for hospital care in the Masisi district in Zaire: a critical evaluation.

In most developing countries, government funding allocated to the health services is not sufficient to allow these services to provide appropriate health care accessible to all. Consequently, community financing has received much more attention in recent years and innovative schemes are being explored throughout the developing world. Risk-sharing schemes, like prepayment, are interesting because of their potential redistributive effects. At the end of the eighties, a prepayment scheme for hospital care was experimented with in the Masisi health district in Eastern Zaire. In the present paper, the experiment is described in a chronological way and the results are analyzed and discussed in detail. Although this particular case-study was not successful, it yields important lessons concerning the design, implementation and evaluation of prepayment schemes for hospital health care in developing countries. More specifically, phenomena like adverse selection and moral hazard are discussed. Finally, conditions for success of similar experiments are discussed. These conditions relate mainly to the organization pattern of the district health services system. The Masisi experiment is a nice illustration of the fact that prepayment is not a 'magic bullet': the lessons drawn from it may be of relevancy to health planners intending to implement hospital prepayment schemes in similar settings.

Paying for health care instead of buying drugs. An experience from western Mali.

This paper gives an overview of what happened when a flat fee cost recovery system for pre-school children was introduced in a rural town hospital in western Mali: the preceding analysis, the implementation of the new scheme, the results and the problems. The most probable explanations for the problems are discussed. It is concluded that, in order to be successful and to attain its objectives, an initiative of this kind--in this environment--requires very careful preparation and commitment, management-wise as well as socially, in order to achieve a sufficient level of common understanding and consensus.

[To screen or systematically treat a population at risk? A method based on the analysis of costs applicable at the level of district health]. / Dépister ou traiter systématiquement une population à risque? Une méthode basée sur l'analyse des coûts utilisable au niveau du district sanitaire.

With severely limited resources, it is necessary for the health services to select the most efficient strategy for managing health problems in a population at risk. A simple method for cost analysis, which can be used at the district health care level, is proposed so that one can choose between selective treatment on the basis of case identification, or indiscriminate treatment of the entire population at risk. The treatment of anaemia at the antenatal clinic in health centres in southwestern Chad was studied and is presented as an example. The conditions for use and the limitations of the method are discussed.

Screening for Trypanosoma brucei gambiense antibodies with the Indirect Fluorescent Antibody Test (IFAT). Effect of age and previous treatment.

This paper reports on some of the findings of a longitudinal multi-round investigation into the predictive power of early signs and symptoms of human African trypanosomiasis caused by T.b. gambiense, in the Rural Health Zone of Kasongo (Maniema, Zaire). It assesses the importance of the effect of age and a history of previously treated sleeping sickness on serological positivity as measured by the Indirect Fluorescent Antibody Test (IFAT), used as a screening test. The impact of including age and a history of previous sleeping sickness as part of the screening process is discussed in terms of sensitivity and positive predictive value. Including weak serological positivity among the screening criteria does not appear to improve the sensitivity of the IFAT test in this setting.

[Typology and performance of first-referral hospitals in sub-saharan Africa]. / Typologie et performances des hopitaux de premier recours en Afrique sub-saharienne.

This descriptive study provides a typology of first referral level hospitals in sub-Saharan Africa. Data are provided on 88 mainly non-governmental hospitals in 25 African countries. They were obtained through a mail survey. The first aspect discussed is the place of the hospital within the spatial organization of the health care district: population served and other health units. This makes it possible to classify the hospitals in three groups. The analysis of the role of the hospital in the management of the district and the support of the peripheral network is based on information about the formal relations of authority, the participation of the hospital in training and supervision, in provision of drugs and in the financial management of the district. This is followed by a description of the human and other resources available in the hospitals, the type and organization of care provided, as well as the performances in terms of outpatient care, inpatient care and technical interventions. Finally, the available information on expenditure and sources of financing is presented.

The national prevalence survey of nosocomial infections in Belgium, 1984.

A national one-day prevalence survey of nosocomial infections was carried out in March 1984 in 106 Belgian acute-care hospitals involving 8723 patients of whom 6130 had undergone surgery. Three infections were studied: surgical wound infection, bacteraemia and urinary-tract infection. One or more of these three infections was recorded in 9.3% of all patients and in 11.8% of surgical patients. Prevalences increased with increasing duration of hospital stay and with higher ages, but the association of HAI with age was no longer significant after correction for duration of hospital stay. Prevalences varied considerably in different specialties. After adjustment for age and duration of stay, there was no association between perioperative antibiotic prophylaxis and the prevalence of the infections studied, but bias due to selection of higher risk patients in the antibiotic group was probable. Larger hospitals had a higher overall prevalence, but populations differed according to the size of the hospital. Bacteraemia was strongly associated with the presence of an intravenous catheter, and urinary-tract infection with a urinary catheter.