Managing non-communicable diseases at health district level in Cambodia: a systems analysis and suggestions for improvement.

BACKGROUND: Cambodia developed its public health system along the principles of the district model and geared its services towards managing communicable diseases and maternal and child health issues. In line with other countries in the region, non-communicable diseases have emerged as a leading cause of adult mortality. We assessed the current capacity of the Cambodian district health system to manage hypertension and diabetes, with a focus on access to medicine for these chronic conditions. METHODS: A case study whereby in three purposely selected districts in an equal number of provinces a total of 74 informants were interviewed: 27 health care providers and administrators, 30 community representatives and 17 managers of specific non-communicable diseases interventions and social health protection schemes. Questions related to the World Health Organization's health system building blocks. Data analysis involved coding, indexing, charting and mapping the data. Following these exercises all information was analysed by kind of respondent and their respective answer to the question concerned. Responses by respondents of three groups of interviewees were compared when appropriate. At 14 health centres and 3 district hospitals the availability of key medicines for hypertension and diabetes in accordance with the National Essential Drug List was assessed. This was also done for essential tools and equipment to diagnose these two conditions. RESULTS: Although there was agreement amongst nearly all interviewees that non-communicable diseases were prevalent, the district health system, including all health systems building blocks and the referral system, was inadequately developed to effectively deal with these conditions. Medicines supply was erratic and the quantity provided allowed for few patients to be treated, for a short period only, mainly at secondary or tertiary level. CONCLUSIONS: Because of the public health, social and economic importance of non-communicable diseases, a rapid response is required. Given the current Cambodian situation, such response may initially be a diagonal approach, with non-communicable diseases services integrated in the National HIV/AIDS Programme. This should happen together with a reorientation of the health system to enable a horizontal approach to non-communicable diseases management in the long term.

Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.

BACKGROUND: For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS: After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS: A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS: The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.

Reduction of postoperative morbidity and mortality in patients with rectal cancer following the introduction of a colorectal unit.

BACKGROUND: Surgery for rectal cancer is associated with high morbidity and mortality rates. The reason for this has been much debated. This population-based study reports the findings on postoperative morbidity and mortality after rectal cancer surgery following the introduction of a centralized colorectal unit in a county central hospital, supervised by a colorectal surgeon using the most recent techniques. METHODS: All consecutive patients with rectal cancer who underwent surgery at four county hospitals in the Västmanland county in Sweden during 1993-1996 (n = 133) were compared with patients who underwent surgery at the new colorectal unit in the county central hospital from 1996 to 1999 (n = 144). RESULTS: The number of operating surgeons was reduced from 26 to four. The postoperative mortality rate decreased from 8 to 1 per cent (P = 0.002) and the total postoperative complication rate was reduced from 57 to 24 per cent (P < 0.001). Surgical complications dropped from 37 to 11 per cent (P < 0.001). The relaparotomy rate fell from 11 to 4 per cent (P < 0.05). Postoperative stay in hospital was reduced from a median of 13 to 9 days (P < 0.001). CONCLUSION: The new organization, with centralized rectal cancer surgery using modern techniques, reduced postoperative mortality and overall morbidity rates to less than half.

[Regional early mortality in relation to social and hospital structure]. / Untersuchung der regionalen Frühsterblichkeit in bezug zu Sozial- und Krankenhausstruktur.

Detailed analysis of governmental mortality statistics yields information on regional differences in the care for preterm infants in West Germany. 68% of newborn infants dying within the first 7 days of life are of low birth weight. In the 11 states, highest/lowest early neonatal mortality fell from 11.6/6.0 to 6.2/3.1 during the years 1978 to 1982. In the 31 administrative districts, a small negative correlation (r = -0.37) exists for neonatal mortality and tax revenue. Increased regional mortality indicates diminished regionalization of perinatal care for preterm infants.