The impact of a community-oriented medical school on mental health services

This paper discusses the impact of the community-based medical school on mental health services. The Gezira mental health programme represents a collaborative work involving the university, the community and the government. It aims at achieving specified objectives: (1) to modify community concepts, attitudes and practices concerning mental health, (2) to ensure community involvement and participation, (3) to extend mental health services, (4) to train PHC staff, and (5) to encourage research. The programme was implemented in three phases: preparatory, implementation, and evaluation. In the evaluation of the impact of the programme on changing community attitudes, the training of staff, the extension of mental health services, and on research, qualitative assessment, through interviews, focus group discussion, supervision visits, and review of reports are used. There is an overall agreement that the programme helped in raising public awareness regarding the concept of mental health, the care of the mentally ill and community participation. Members of the health team who received training as part of the programme reported a better understanding of mental health problems and an improvement in their handling of the mentally disturbed patients. Teachers reported an increased awareness of mental health problems in school children and a better collaboration with those involved in the handling of such problems. Social workers and psychologists updated their knowledge and skills and were well prepared to participate in the programme. Members of the different sectors involved reported a better standard of collaboration regarding mental health activities. These findings indicate that this programme, by providing a new model for health services in this field, has induced a large policy change within the Sudan. The community-based activities at the FMUG have resulted in a major change in the delivery of mental health services in Gezira State. The programme has resulted in a major shift in mental health services being provided by central hospitals to PHC settings. In addition it has stimulated research, thereby providing much original information that will help in preparing for future plans.     

Improving access to services and interactions with clients in Guatemala: the value of distance learning

OBJECTIVE: To develop and test a distance-learning programme to improve the quality and efficiency of family planning services in Guatemala. METHODS: The setting was rural family planning services in Guatemala. The study design was quasi-experimental with one intervention and one control group and with pre- and post-intervention measures. Two staff members from each of 20 randomly selected health districts were trained as leaders of the training programme. In turn, the 40 trainers trained a total of 240 service providers, under the supervision of four health area facilitators. The results were compared with 20 randomly selected control health districts. The intervention was a distance-learning programme including 40 in-class hours followed by 120 inservice practice hours spread over a 4-month period. Distinctively, the programme used a cascade approach to training, intensive supervision, and close monitoring and evaluation. Patient flow analysis was used to determine number of contacts, waiting times, and the interaction time between service providers and clients. Consultation observations were used to assess the quality and completeness of reproductive health information and services received by clients. RESULTS: The intervention showed a positive impact on reducing the number of contacts before the consultation and client waiting times. More complete services and better quality services were provided at intervention clinics. Some, but not all, of the study objectives were attained. The long-term impact of the intervention is as yet unknown. CONCLUSION: Distance-learning programmes are an effective methodology for training health professionals in rural areas.     

High-tech home health care: administrative and staff perspectives

This study examines staff perspectives and personnel issues related to the delivery of high-tech home health care services to older adults. Data were collected from a national sample of 154 agency directors and 92 local agency staff. Agency staff and directors consistently report an increase in high-tech service delivery over the past five years. Both agency directors and local staff agree that a variety of staff may be involved in the delivery of high-tech services, including both professional and paraprofessional staff. Although agency directors report providing training to at least one or more type of direct care staff, agency staff are less likely to report being required to participate in training programs. The provision of high tech services impacts the agency, the staff, and the patient in various ways. Most staff feel that high-tech care enhances the quality of life of older patients, although high-tech care may be somewhat difficult to define and even more difficult to deliver. Challenges related to the provision of high-tech care, including providing adequate staff training, and developing appropriate quality assurance measures, are discussed.     

High-Tech Home Health Care

This study examines staff perspectives and personnel issues related to the delivery of high-tech home health care services to older adults. Data were collected from a national sample of 154 agency directors and 92 local agency staff. Agency staff and directors consistently report an increase in high-tech service delivery over the past five years. Both agency directors and local staff agree that a variety of staff may be involved in the delivery of high-tech services, including both professional and paraprofessional staff. Although agency directors report providing training to at least one or more type of direct care staff, agency staff are less likely to report being required to participate in training programs. The provision of high-tech services impacts the agency, the staff, and the patient in various ways. Most staff feel that high-tech care enhances the quality of life of older patients, although high-tech care may be somewhat difficult to define and even more difficult to deliver. Challenges related to the provision of high-tech care, including providing adequate staff training, and developing appropriate quality assurance measures, are discussed.     

Mental health training and development needs of community agency staff

Emphasis has long been placed in UK national policy on providing 'seamless' mental health services to meet both the health and social care needs of service users. While attention has been paid to the training required by specialist mental health and primary care staff in order to achieve this, the needs of other community agency staff have received less attention. The present article describes a study designed to identify the training needs of staff working within a broad range of agencies. Focus group discussions were used to explore participants' experiences of mental health problems amongst clients, their confidence in dealing with these, current sources of support and perceived training needs. The results indicate that participants in all agencies routinely encountered a range of problems. Colleagues were the main source of support, followed by line managers, but supervision structures and wider organisational support were lacking in some cases. Joint working with specialist mental health services was almost universally problematic and all groups identified a range of training needs. On the basis of the results, the present authors put forward suggestions as to how these needs might be met.     

The impact of supervision on stock management and adherence to treatment guidelines: a randomized controlled trial

Ensuring the availability of essential drugs and using them appropriately are crucial if limited resources for health care are to be used optimally. While training of health workers throughout Zimbabwe in drug management (including stock management and rational drug use) resulted in significant improvements in a variety of drug use indicators, these achievements could not be sustained, and a new strategy was introduced based on the supervision of primary health care providers. This was launched in 1995 with a training course in supervisory skills for district pharmacy staff. In order to evaluate the impact of the supervision and the effectiveness of the training programme, adherence to standard treatment guidelines (STG) and stock management protocols was evaluated in a randomized controlled trial. The study compared three different groups of health facilities: those that received supervision for either use of STG (n = 23) or stock management (n = 21) - each facility acting as control for the other area of supervision - and a comparison group of facilities which received no supervision (n = 18). On-the-spot supervision by a specially trained pharmacy staff, based around identified deficiencies, took place at the start of the study and 3 months later. The evaluation compared performance on a variety of drug management indicators at baseline and 6-8 months after the second supervisory visit. The results of the study showed that, following supervision, overall stock management improved significantly when compared with the control and comparison groups. Similar improvements were demonstrated for adherence to STG, although the effect was confounded by other interventions. The study also showed that supervision has a positive effect on improving performance in areas other than those supervised, and demonstrated that pharmacy technicians with limited clinical skills can be trained to influence primary health care workers to positively improve prescribing practices. Allocating resources to supervision is likely to result in improved performance of health workers with regard to the rational use of essential drugs, resulting in improved efficiency and effectiveness.     

Support workers in intermediate care

Despite the proliferation of support worker roles in the UK, little is known about their actual numbers, employment conditions or levels of training. Intermediate care services appear to be an important employer of support workers, but the diversity of intermediate care services makes the task of understanding support worker roles even more complex. This paper presents data from 33 services which were involved in an NHS Modernisation Agency's Changing Workforce Programme project, the Accelerated Development Programme for Support Workers in Intermediate Care in England. Within this project, the main employers of support workers were primary care trusts and/or social services. Participating intermediate care teams were involved in admission avoidance, assisted discharge and reablement, or combinations of these services, and the majority of care was provided in the patient's own home. The 33 services employed 794 support workers and 368 professionally qualified staff. The mean ratio of professionally qualified staff to support workers was 0.95 (range = 0-4.9, SD = 1.05). Support worker roles included multidisciplinary working, meeting rehabilitation needs, providing personal care and enablement. Team leaders included nurses, social workers, physiotherapists, professional managers, home carers and support workers. The most commonly reported sources of support worker training were National Vocational Qualifications and in-house training. In 80% of the services, at least half of the support workers had a qualification. Three models of supervision emerged across the services: the allocation of a mentor; team supervision; and formal and informal line management. These findings illustrate the diversity of employment of support workers in intermediate care. The variations in training, supervision and skill mix have implications for clinical governance and support worker regulation. The employment of support worker staff jointly across health and social care raises cross-boundary issues around employment contracts and pay.     

Training for health care in developing countries: the work of the Tropical Health and Education Trust

The Tropical Health and Education Trust (THET) was established to strengthen medical education and training for health care in developing countries. The Trust responds to requests from training institutions with a wide range of activities and programmes. Projects to meet specific needs are planned in outline with the Deans or Directors of institutions, as a basis for a long-term link with a similar institution in the United Kingdom. These links are now the preferred method for meeting requests to develop skills, strengthen services and promote staff development. However, funding is always necessary for their support. THET has promoted students' community-based training by enabling students in a team-training programme in Ethiopia to make interventions in primary health care. A prize for the best students' community, clinical or laboratory projects in six African countries encourages enquiry by the students, promotes independent learning, and relates academic work to problems in health care. Work with Ministries of Health includes a continuing medical education programme for rural medical officers in Uganda, courses in basic and life-saving surgery for Ethiopian health and medical officers, and a programme to update the skills of laboratory technologists in rural hospitals in Ghana. The range of projects that THET supports is wide because the needs, defined by those who are working in, and responsible for, training in the health service are diverse.     

Community-based health care in Kibwezi, Kenya: 10 years in retrospect

In response to the interest of the Kenya government in community-based health care, the Kibwezi Rural Health Scheme was developed by the African Medical and Research Foundation (AMREF) in a semi-arid district in eastern Kenya. Based on a community co-operative philosophy and focussing on health promotion and prevention, the scheme includes the following: a health centre with a 15-bed in-patient unit including four maternity beds, out-patient services, and a 15-bed nutrition rehabilitation unit; a cadre of volunteer community health workers, trained by AMREF, who form the backbone of the project; maternal child health/family planning and nutrition services including an applied nutrition programme, a water project; and a mobile health unit. Designed as a replicable model health programme, the intention was that services would be gradually taken over by the Ministry of Health of Kenya. Much has been learned in the development of the project which should be meaningful to others considering similar endeavours. One of the first lessons learned was that the time taken to sensitize the community to community-based health care is critical to the success of the project and may need to be as long as 1-2 years. Another was that gaining the support of the community for the community health workers (CHW) requires a considerable effort on the part of project staff, but seems to be the only viable solution to the remuneration and recognition of the CHW's work. It also became apparent that preventive and promotive health services should be integrated structurally and operationally with curative health services to provide the most benefits for the community served. Finally, although there are some differences of opinion, it is felt that with some refinements, the project could be replicated in other parts of Kenya.     

A staff support programme for rural hospitals in Nepal

ProblemDistrict hospitals in Nepal struggle to provide essential services such as caesarean sections.ApproachRetention of health workers is critical to the delivery of long-term, quality health-care services. To promote retention and enhance performance in rural public hospitals, the Government of Nepal and the Nick Simons Institute progressively implemented a rural staff support programme in remote hospitals. After competitive selection for a compulsory-service scholarship and training, family practice doctors who could do basic surgery, orthopaedics and obstetrics were hired under a binding three-year contract in each participating hospital. Comfortable living quarters and an Internet connection were provided for the resident doctors; in-service training for all staff and capacity development for each hospital’s management committee were provided.

Local setting

Nepal’s mountainous landscape, poverty and inequitable rural/urban distribution of health workers pose barriers to adequate health care.

Relevant changes

Between 2011 and 2015 family practice doctors were maintained in all seven programme hospitals. All hospitals became providers of comprehensive emergency obstetric care and served more patients. Compared with hospitals not within the programme, deliveries increased significantly (203% versus 71% increase, respectively; P = 0.002). The programme recently expanded to 14 hospitals.

Lessons learnt

A package of human resource supports can improve the retention of doctors and the use of remote hospitals. Factors contributing to the success of this programme were compulsory-service scholarship, central personnel management, performance-based incentives and the provision of comfortable living quarters.     

The Extent of Barriers and Linkages to Health Care for Head Start Children

Data were gathered as part of a larger survey of 218 Head Start Programs in Region II (New York City, New York State (excluding New York City), New Jersey, Puerto Rico and U.S. Virgin Islands) in 1993–94. The general purpose of the survey was to obtain information on child health, screening practices, training needs, family health and community problems, barriers to diagnosis and treatment and the extent of linkages between Head Start programs and health and nutrition providers at the local level. In this study barriers to the care of Head Start children and their families were examined as perceived by the Health Coordinators or other health related staff of the Health Services Component of these programs. The extent of linkages with health and nutrition service providers were also examined. The most frequently reported barriers were lack of parent participation (72%), private transportation not available (67%), parents' perception of quality of care (64%), distance to provider (63%), cost of transportation (63%), lack of funding (56%), limited/inconvenient hours (56%), and health services not available in the community (55%). On average, programs reported linkages to 14.5 providers (including an average of 4 nutrition programs). More than 90% of them reported linkages with public health services, child protective services, WIC and private physicians/dentists. Finally, the extent of barriers and linkages were compared across different geographic areas. Significant barriers were identified in this study, yet the survey confirmed and validated the extensive nature of formal linkages with health and nutrition service providers at the local levels. These findings may indicate that the current levels of service availability may not be sufficient to meet the severity and diversity of health needs of this population.     

Rating maternal and neonatal health services in developing countries

OBJECTIVE: To assess maternal and neonatal health services in 49 developing countries. METHODS: The services were rated on a scale of 0 to 100 by 10 - 25 experts in each country. The ratings covered emergency and routine services, including family planning, at health centres and district hospitals, access to these services for both rural and urban women, the likelihood that women would receive particular forms of antenatal and delivery care, and supporting elements of programmes such as policy, resources, monitoring, health promotion and training. FINDINGS: The average rating was only 56, but countries varied widely, especially in access to services in rural areas. Comparatively good ratings were reported for immunization services, aspects of antenatal care and counselling on breast feeding. Ratings were particularly weak for emergency obstetric care in rural areas, safe abortion and HIV counselling. CONCLUSION: Maternal health programme effort in developing countries is seriously deficient, particularly in rural areas. Rural women are disadvantaged in many respects, but especially regarding the treatment of emergency obstetric conditions. Both rural and urban women receive inadequate HIV counselling and testing and have quite limited access to safe abortion. Improving services requires moving beyond policy reform to strengthening implementation of services and to better staff training and health promotion. Increased financing is only part of the solution.     

A survey of local public health departments and their directors.

In 1974 a questionnaire was mailed to the nation's local health officers. Responses were received from 1,345, at least 68 per cent of all local health departments. The present paper presents selected summary data from respondents concerning the health departments, their jurisdictions, organization, finance, functions, staffing, and about the training, salaries, and other characteristics of local health officers. Health departments are extensively involved in rendering health services, including direct personal services (25 per cent of all departments). For many services the health department is the sole provider of essential services in the area of jurisdiction. These services include ambulatory care (8 per cent), maternal and child health (48.5 per cent), home care (44.8 per cent), and family planning (38 per cent). The major constraints to improvement and expansion of programs are perceived as limited financial support, insufficient staff, and inadequate facilities.     

Nutritional interventions through primary health care: impact of the ICDS projects in India

In 1975 the Government of India initiated an integrated approach for the delivery of health care as well as nutrition and education services for deprived populations at the village level and in urban slums through centres, each of which was run by a local part-time female worker (anganwadi) who was paid an honorarium and had a helper. This national programme, known as the Integrated Child Development Services (ICDS), began with 33 projects but, by March 1986, had expanded to 1611 projects covering 23% of the country's population and representing about 50% of the population in the socioeconomically backward areas. The ICDS can therefore be considered to function as a primary health care programme for preschool children (under 6 years old), pregnant women, and lactating mothers. The present study investigated the impact on the nutritional status of the target population after 3-5 years and after 8 years of ICDS interventions, compared with the nutritional status of non-ICDS (control) groups. The results showed that the ICDS nutrition intervention programmes achieved better coverage of the target population and led to a significant decline in malnutrition among preschool children in the ICDS population, compared with the non-ICDS groups that received nutrition, health care and education through separate programmes. This example may lead other developing countries to introduce integrated programmes with certain modifications to suit local conditions. International agencies and national governments should strive to bring about the integration of nutritional services with primary health care and development programmes for children because of the good results in terms of child survival and child development.     

重庆市某区妇幼保健人力资源的定性研究

目的:了解该区妇幼保健人力资源的现状及影响因素。方法:采用关键人物访谈、个人深入访谈及专题小组访谈进行调查。结果:每个乡镇最多只有1~2名妇幼保健专职人员,人员学历以中专生居多,年龄偏大,大多数妇幼保健人员为兼职,其专业知识和技能不足。影响因素包括国家对妇幼保健投入不足,医疗保健机构管理和培训机制、激励和考核机制不健全,基层医疗保健机构在人员引进方面存在较多困难,医学教育对妇幼保健专业重视不够。结论:基层妇幼保健人员匮乏,整体素质不高,队伍不稳定,影响因素较多,需要从管理、培训、激励和考核等方面加强妇幼保健人力资源的建设。     

Better education for better health care

In India, all national nutrition programs and activities are carried out by staff at the primary health centers under the leadership of medical officers. A study of 114 of these officers from 80 primary health centers in rural districts of Andhra Pradesh State was undertaken to assess their knowledge and performance, particularly with regard to nutrition and related matters. Scores were expressed in percentages, with under 50% considered poor, 50-75% satisfactory, and over 75% good. The highest score 67.7% was obtained on knowledge of nutrition and related areas, and the lowest, 19.7% was for the participant's awareness of their own job responsibilities. Although overall theoretical knowledge on nutrition and related matters was satisfactory, significant gaps existed. A majority were ignorant as to how many people were covered by their centers and the numbers of staff in different categories, suggesting little attention was being given to planning and implementation of various services. Only 23% were aware of their own responsibilities regarding nutrition, and only 16% mentioned teaching nutrition during their training programs. The conclusion is that the medical education system must be better coordinated with the health care delivery infrastructure. Medical undergraduates need more exposure to Practical aspects of health care in rural communities, managerial aspects of work in primary health centers, and programs with a stronger nutrition component. In addition, refresher courses must be offered, and the problem of overburdening the medical officers must be dealt with.     

Enhancing health programme efficiency: a Cambodian case study

In 1995, the Cambodian Urban Health Care Association (CUHCA) was set up as facilitator between private health care providers and patients, guaranteeing good quality health care and fair pricing to patients and providing training and logistic support to providers. Providers were engaged on a fee-for-service basis and competition encouraged. CUHCA's objectives followed the same line of thought as the 1993 World Development Report, aiming at influencing the unregulated private health care market through competition mechanisms. But soon after the start of the project the basic problem was recognized to be not the absence of effective government regulation but rather that consumers lack the requisite knowledge to make good choices in the market for health services. CUHCA had not adequately addressed the demand for health services. The original supply-side strategy of improving health services by increasing competition was a failure. In order to improve CUHCA's health programme efficiency the association's objectives were subsequently redefined and its functioning reorganized. CUHCA now tries to educate consumers and provides good quality services so that consumers will be able to act on the basis of their newly acquired knowledge. CUHCA's health centres serve as model clinics for first-line health care. Community educators organize information, education and communication (IEC) activities. Staff help school teachers to improve formal health education in schools and CUHCA assists local leaders in sanitation development. Only full-time personnel are employed, encouraging team spirit and communication with the target population. Salaries are based on team performance. The CUHCA programme demonstrates that, depending on the market situation, health programme models need to address both the supply and the demand for services in order to be efficient. Where consumers lack essential knowledge to make appropriate choices in the health service market, interventions should focus on health education and social marketing and provide models of quality care catering to informed consumer choice.     

Economic contribution of gynecological and obstetrical ultrasound in an advanced strategy for the Zinguinchor region

Aiming to strengthen the accessibility of ultrasound technology to rural populations, an advanced strategy ultrasound programme was implemented in the health districts of Sedhiou, Oussouye, Bignona and Ziguinchor all located within Casamance in Senegal. Within the first year of activity (January 1, 2001-December 31, 2001), the team from the regional health centre (RHC) was dispatched 56 times. Ultrasound scans were performed in the homes of 1,273 patients among which 192 were referred to the RHC for specialised follow-up and treatment. The financial benefit for the RHC totaled 3,120,000 francs; 2,612,500 francs for the district hospital; and 3,561,300 francs for the population at large. The advanced strategy for performing ultrasound scans has therefore been economically profitable at the community level as much as at the level of health structures. Through supporting the activities of the district hospitals, the RHC contributed technical support and increased the potential, not solely for the treatment of disease but for the health services overall. The revenue generated has given managers a greater possibility to improve health care and services. The decentralisation programme and reduction in the cost have decreased the unsatisfied needs in ultrasound services by making the technology more financially and geographically accessible. Thus, by saving input costs in terms of time, transportation and capital, the practice of ultrasound scans in district hospitals has been strengthened and has improved the capacity to provide care and treat the population's health problems. The continuation of this programme is advantageous, but necessitates two complementary actions: enhancing of the technical level and capacity of the district hospitals with the installation of ultrasound technology and equipment, and raising the level of knowledge by training staff in administering ultrasound scans.